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- Nursing in History
- Levels of Licensed Nursing Practice
- Types of Nursing Education
- Nursing Careers
- Are Nursing School and a Nursing Career for You?
- Choosing a Program
- Getting Into a School
- Paying for School
- Course Subjects
- After You Graduate
Despite our efforts to prevent and relieve it, there is still a terrible amount of suffering in the world. While the rates of illness and death from infectious disease and malnutrition have gone down in developed countries, the same rates from cancer and circulatory disease have risen. Genetic defects, accidents, and violence take their toll; population density makes the impact of natural disasters worse than it once was. Although medical science has helped us to achieve longer life spans, we often require medical assistance to live through those extra years. As much as we need doctors, there is also a need for nurses to work with patients and translate doctors recommendations into real health improvements or pain relief.
Nursing schools can not only prepare you for a great and financially rewarding career, they can also give you the knowledge and skills you need to make a difference in peoples' lives. This can take place in a hospital, hospice, doctor's office, school, camp, nursing home, or patient's residence. "I want to make the world a better place" might be a cliche, but there are few better ways to do it than by studying and practicing nursing.
From the dawn of human societies, people have attempted to heal one another and care for the sick and wounded. In Western cultures, doctors eventually replaced shamans and medicine men; semi-professional nurses came on the scene to assist family care givers; and in cities, the focus of major health care moved from the home to specialized medical districts. While some people identify the theater of Hippocrates (he of "Hippocratic Oath" fame) on the Greek island of Kos as the world's first hospital, it's more probable that first hospital we would recognize as such was founded in Jerusalem by the Knights Hospitalers of St. John in the 11th century AD.
The first "nursing school" is said to have been founded in India in about 250 BC; according to the document known as The Charaka, it trained only men "of good behavior, distinguished for purity, possessed of cleverness and skill, imbued with kindness, skilled in every service a patient may require, competent to cook food, skilled in bathing and washing the patient, rubbing and massaging the limbs, lifting and assisting him to walk about, well skilled in making and cleansing of beds, readying the patient and skillful in waiting upon one that is ailing and never unwilling to do anything that may be ordered." For the next 2000 years, men and women received training in caring for the sick and wounded in many different ways: from healers and physicians, from hospitals and hospices, and from military organizations. But one war, and one woman, would change nursing and nursing education forever.
In 1853, war broke out between Russia and the Ottoman Empire (now Turkey), and England and France soon entered the war on the side of the Ottomans. In 1854, English and French forces attempted to invade the peninsula called the Crimea, in what is now The Ukraine, expecting to surprise the Russians and meet little resistance. The "Crimean War" turned into a fiasco; strong Russian defenses and horrible strategic decisions caused massive allied casualties. Because of poor logistical support, malnutrition, and little or no sanitation and hygiene at the main allied barracks hospital, appalling numbers of wounded British soldiers died from disease. The British government allowed a woman named Florence Nightingale to try to set things right. Nightingale was trained in nursing despite her wealthy family's strong objections. She led a team of nurses to the barracks hospital and virtually singlehandedly overhauled the treatment of the soldiers there. The result was a dramatic reduction in the hospital's rates of disease and death. She went on to revolutionize nursing, health care, and hospital design throughout Europe and in India, founded the Visiting Nurse Association, contributed to the founding of the British Army Medical School, and gave her name to the Nightingale Training School for Nurses at St. Thomas' Hospital in London. The "Florence Nightingale Pledge," written for the graduates of Detroit's Farrand Training School for Nurses, is to nurses what the Hippocratic Oath is to doctors.
Less fortunately, the medical establishment also adopted Nightingale's Victorian conception of nursing as a nurturing, maternalistic female-only profession. While famous poet Walt Whitman was one of many male nurses who would assist the Union and Confederate armies during the American Civil War, the number of men working in nursing in North America and Europe greatly declined and remained very low for over a century. Women would be responsible for most of nursing's early milestones. The first "trained nurse" (by modern standards) in the US, Linda Richards, received her diploma from the New England Hospital for Women and Children in 1873. Nursing superintendent Clara Barton helped found the American branch of the Red Cross in 1881 and steered the whole organization into peacetime disaster relief work. Ethel Bedford-Fenwick founded both the British Nursing Association and the first professional nursing publication (the British Journal of Nursing), then became the world's first mandatorily registered nurse in 1919.
In the US, many professions began opening to women starting in the 1960s and 70s; conversely, nursing began opening to men. Males now make up over 6% of nursing professionals, which seems like a small percentage but is still higher than it's been in the past hundred years. Simultaneously, community colleges and other vocational training institutions began to offer nursing education in areas where it hadn't previously been available, and to people who wouldn't previously have been able to get it. But the supply of nurses still hasn't risen as fast as the demand for them. This first decade of the 2000s has become a time of opportunity for those who want to study nursing: nursing programs are widespread and affordable, and employment for skilled and motivated graduates is almost assured.
In the US, there are four "levels" of licensed nursing personnel. In general, the higher the level you are, the more procedures you are allowed to do and the more money you can earn (but the more responsibility you have as well).
- It takes relatively little training to become a certified nursing assistant (CNA), but compared to other healthcare personnel, CNAs aren't allowed to do very sophisticated tasks either. CNAs -- once known as "orderlies," now more often referred to as "nurse's aides," "home health aides," or "patient care technicians" -- aren't actually nurses themselves, but perform tasks as directed by nurses. Exactly what they're expected to do and not do will vary depending on where they're working, but the tasks usually involve basic day-to-day non-invasive patient care: assisting them with dressing, bathing, feeding, walking, and going to the bathroom; taking their vital signs; turning them in bed; making their beds; helping them into and out of wheelchairs; etc. CNAs can get their certification after as little as a few weeks in the classroom and a month or two of on-the-job training.
- Licensed practical nurses (LPNs) and licensed vocational nurses (LVNs) are "basic" nurses on the front lines of health care. What they're permitted to do varies from state to state, but in addition to the basic patient care that CNAs can perform, LPNs/LVNs can usually do some combination of tasks like these: help develop care plans for patients and assess patients progress; communicate with patients about their health (teaching them about new medications they've been prescribed or new procedures or exercises they've been asked to do, for example); dress wounds; apply compresses; give alcohol rubs and massages; administer some medications; give some injections; start IVs; insert catheters; take samples for testing and perform some simple lab tests; help in delivery rooms; feed and bathe newborns; and perform CPR as necessary. However, LPNs/LVNs can't fill doctors orders directly; they can only take direction from higher level nurses. LPNs/LVNs can get their license after as little as a year of diploma education. Although many hospitals have a policy of not employing LPNs/LVNs, this is changing in the face of the current nursing shortage. Nursing homes continue to employ many LPNs/LVNs.
- Registered nurses (RNs) are "full-spectrum" nurses who can do a wide variety of medical procedures as directed by doctors. Besides all of the tasks that LPNs and LVNs can do, RNs can operate monitors and other medical equipment; give almost all medications and injections; administer IVs on an ongoing basis; assist in surgery; administer care plans; supervise other nursing personnel and sign off on their work; and much more, depending on their work environment. RNs can get their license after a minimum of two years of diploma or associate degree study, although many hospitals prefer RNs to have a four year bachelor's degree.
- Some types of complex, specialized nursing care are reserved for advanced practice registered nurses (APRNs). You need an additional specialty license to become any of these APRNs: Certified Registered Nurse Anesthetist (CRNA), Certified Nurse Midwife (CNM), Certified Nurse Specialist (CNS), Certified Nurse Specialist for Psychiatric/Mental Health (CNS-PSYCH), or Nurse Practitioner (NP). Most APRN licenses require at least four years of study, a bachelor's degree, and some postgraduate study; some require a master's degree or more.
Nursing education is available almost anywhere in the world that has modern medical care; you can search the directory on our main page and the information in our international page to find a nursing program near you. Several types of nursing programs are available:
- Hospital-based diploma programs: At one time, all
"nursing schools" were affiliated with hospitals; although many fewer health
facilities offer nursing education now, some still do. Some examples: Bridgeport Hospital School of Nursing in
Bridgeport, Conn., and Christ Hospital
School of Nursing in Cincinnati, Ohio. Students usually study at the facility under people who
actually work there, graduating in two to three years with a diploma.
Dan Cook, staff nurse at Mercy Hospital in Pittsburgh, Penn. (which also operates a nursing school), graduated from the Ohio Valley General Hospital School of Nursing in Kennedy Township, Penn; he recommends that students strongly consider going to a hospital based school. "They're much less expensive, for one thing. Plus, in a hospital program, you start getting clinical experience from day one. In a four year college program, you get more book learning, but you might not get actual experience with patients until your junior or senior year. Suppose a student finds out, when they actually start working with patients, that they're not cut out to be a nurse? If you've gone to a four year school, that's a lot of time and money spent on training you might never use."
- Degree and diploma programs at community colleges: Large numbers of American community colleges offer nursing diplomas and Associate Degree in Nursing (ADN) programs. ADN students typically graduate in two to two and a half years. Some community colleges offer "accelerated" Bachelor of Science in Nursing (BSN) programs that can be completed in as little as three years.
- Undergraduate programs at traditional colleges and
universities: Many colleges and universities offer Bachelor of
Science in Nursing (BSN) programs as well as RN-to-BSN programs for registered
nurses who only have diplomas or associate degrees.
Students who study for a BSN "from scratch" can graduate with one in three to four years. RN-to-BSN students can graduate in a year to two years if they can go to school full time, but will probably take much longer if they have to attend classes around their work schedule. That's the main reason that Sandra Gray, a registered staff nurse with the Visiting Nurse Association of Western PA, recommends that prospective nurses go for their BSN right away: "Go for a degree program if you want the maximum possible opportunity when you graduate -- if you want to be a school nurse or a teaching nurse, for example. If you get a diploma or associate degree, you'll have to take additional courses while you work at some other job, a few credits at a time for several years, until you have what you need for something better."
- Graduate programs at colleges, universities, and hospitals: Quite a few colleges and universities, and some hospitals, offer Master of Science in Nursing (MSN) programs, RN-to-MSN programs, graduate specialty diplomas, or even PhD doctorates for students that want to pursue advanced nursing work or research. Institutions that offer graduate studies in nursing include Lewis University in Romeoville, IL; Excelsior College in Albany, NY; the University of Leeds in Leeds, UK; Chonnam University in Kwang Ju, South Korea; and The Queen Elizabeth Hospital in Woodville, Australia. If you start with a BSN, graduate diplomas can be earned in a year or two; an MSN will require two years; a PhD will require four years and a dissertation.
- It is increasingly possible to replace classroom based courses (but not clinical experience) with online education. If you want to take classes online, be careful to take them from a reputable, accredited school whose credits will be transferable elsewhere and will be recognized as legitimate by other schools and employers. Among others, the University of Phoenix and Jacksonville University both offer online nursing course work.
Many people's conception of nursing is limited to "caring for frail or sick old people in a home or hospital ward." It's true that more nurses than ever are needed to provide that type of care. But many nursing specialties and careers can take you beyond "Good morning, Mrs. Hoskins, are you feeling any better today?". Here are a few of them:
Pediatric (children's) nurses care for children and adolescents: monitoring their growth and development, treating and trying to prevent their illnesses, helping them with asthma and other chronic problems, and working with them to overcome any disabilities they might have.
School nurses help kids in away-from-home schools. They make sure children are immunized, give eye and ear tests to make sure that any problems with those faculties are detected and corrected, treat injuries and illnesses that occur at school, teach and counsel kids about their health, and sometimes provide daily assistance to "mainstreamed" children with severe medical challenges.
College nurses assist older young people and adults at colleges and universities. They too treat illnesses and injuries, but they typically do more counseling and education to try to prevent psychological problems, alcohol and drug abuse, unintended pregnancy, sexually transmitted disease, and other health concerns that occur more often at college campuses.
Nutritionists make sure that patients get food and drink that will best meet their various health needs.
Peri operative (operating room) nurses assist before, during, and after surgery. Among peri operative nurses, RN first assistants provide direct nursing care to the patient being operated on; scrub nurses pass supplies and instruments to and from surgeons inside the sterile area surrounding the patient ("scalpel...forceps...retractor..."); and circulating nurses handle the nursing tasks outside the sterile area.
Nurse anesthetists help prepare patients for surgery, give them anesthesia during surgery or childbirth, and assist them through recovery.
Critical care (or acute/intensive care) nurses are called on to watch over patients with the most critical health needs: either acute situations requiring an emergency room visit or chronic situations requiring intensive, cardiac, or highly complex care.
In seeking to improve the health of their patients and the work environment of their staff, nursing administrators and managers don't only give care, they design it; they not only follow policy, they make it; they don't just make do with the resources they have, they help to allocate the resources.
Hospice nurses make the process of dying easier for terminal patients and their families. They provide emotional support and whatever physical care is required to minimize patients pain and symptoms while maximizing their dignity.
Public health nurses attempt to keep entire communities as healthy as possible by preventing and containing the spread of disease and the incidence of environment related health problems, as well as by educating people how to maintain their wellness. They are employed by community organizations ranging in size from camps and schools to city health departments and HMOs.
Psychiatric and mental health nurses assess and respond to people's mental health needs, whether it be in a counselor's office, a hospital psych ward, or in an evacuation center during a natural disaster.
Occupational nurses are concerned with the health and safety of employees in the workplace. In normal situations they try to help workers stay well and productive and prevent the types of ergonomic problems that lead to stress injuries. When accidents occur, they make sure that employees get the medical attention they need and that worker's compensation, if necessary, is dealt with correctly.
Sports nurses try to keep athletes and sports enthusiasts in optimum physical shape, advising them how to stay well and treating injuries if they occur.
Military nurses care for soldiers: treating their injuries and illnesses, giving psychological and moral support, and helping them to be as physically prepared as possible to do their duty.
Forensic nurses treat victims of crimes, particularly sexual assaults, with a view toward not only healing the patient but also solving the crime.
Nursing researchers/scientists research and evaluate all aspects of the nursing practice, including the effectiveness of nursing tools, methods, and procedures.
So are you the kind of person who makes a good nursing student and then a good nurse? Dan Cook points out some things you need to consider: "Being able to help people with their health needs is a wonderful thing, and it's terrific if you want to learn how and do that. But there are a lot of things you'll need to be able to do: Spend long hours on your legs. Be multi tracked enough to care for six to ten patients at the same time. Put aside what you might feel about patients and prioritize your care by the sickest patients first. Maintain patients privacy and the confidentiality of their information. In some nursing jobs, you might be called on to care for prisoners. And because some facilities can't afford not to hire qualified nurses even if they're unpleasant or lazy people, you might need to be able to shrug off personal conflicts and pick up slack for others." Sandra Gray adds that prospective visiting nurses should have "well rounded experience," so that they can deal with many different health concerns (and other issues that patients might have) on their own, outside a hospital environment; they should also have the patience and communication skills to both listen to homebound patients -- many of whom are elderly -- and to respond to their questions and teach them what they need to do to maintain their health.
Dan Cook also identifies a lot of benefits that go along with a nursing career. "Once you've been working there awhile, some places let you pick the schedule you want to work. Full time nurses usually get good benefits, and good medical care if they get sick. Many nurses have access to credit unions for better savings returns and less expensive loans. You'll have a 401(k) or pension plan. You can help people get better and feel better, of course, which is satisfying. Hopefully you're learning new medical procedures all the time. If you work at a teaching hospital, you'll be able to get help from interns and residents." Sandra Gray likes the independence of being a visiting nurse, and she also likes the freedom of arranging her hours: "You can schedule visits around your own appointments, although you have to do more work at home than a non-visiting nurse would."
We'll talk more about landing a nursing job later in this article, but if you think you want to get a nursing education, there are things you can do to prepare for a career before you even start school. Esther Atwood, Nurse Preceptor Educator at Armstrong County Memorial Hospital (ACMH) in Kittanning, PA, suggests that you try doing volunteer work in a medical setting, perhaps with an ambulance service, in a hospital auxiliary, or as a CNA. This will not only give you valuable experience, but it will also help you to figure out whether a nursing career is right for you. She goes on to point out that you can make valuable contacts with potential employers at high school career days and job fairs, and that many hospitals, including ACMH, are also willing to employ student nurses as CNAs while they go to school and then as full nurses after they graduate and earn their license. You might want to talk to human resource personnel at hospitals near you about this possibility before you even apply to a program.
One of the basic concerns you'll have about any type of school you want to attend is the location of its campus, if it has one. If you'll be commuting from home to school, you'll want a campus with either good public transportation or good parking. If you'll be living on the campus away from home while attending school, you'll want a campus with plenty of services (stores, restaurants, Laundromats, etc.). Keep in mind that attending a nursing school outside the U.S. is not necessarily an impediment to getting a good nursing job in the U.S.; refer to the Commission on Graduates of Foreign Nursing Schools Web site for more information.
It's a good idea to visit the physical facilities of any school you might want to attend. (Even an online nursing school will be affiliated with various hospitals or other medical educational settings where you can get your practical experience.) Are the buildings clean? Are they equipped to train you on the latest medical technology and procedures? If you'll be attending the school as part of a "train here and get a job here when you graduate" program, is it a place you'll feel comfortable both learning and working?
In the "Levels of Licensed Nursing Practice" and "Types of Nursing Education" sections above, we discussed different varieties of nursing work and education and the venues in which you'd pursue a nursing education. Generally speaking, while it's possible to finish CNA or LPN training in less than two years, which gets you through school at low cost and into the job market quickly, the positions you'll qualify for aren't liable to be either challenging or lucrative, nor is there liable to be much chance for advancement. Two to two and a half years will get you a diploma or ADN leading to an RN; three or more, a BSN. Though the extra time costs more, the career possibilities are much greater. With loan forgiveness for nursing students as prevalent as it is, the higher cost is less of a problem anyway.
That being said, if you're thinking about enrolling in a high priced program, you'll still want to make sure it's really worth the extra investment. A large, heavily attended four year school might have better equipment and a more decorated nursing faculty, and its "core curriculum" of basic English, math, science, and other courses will stand you in good stead for life in general. But is its RN or BSN program really going to be more useful to you than one offered by a hospital or a community college? Dan Cook cautions, "How much do you want to pay for the same nursing degree -- $18,000 or less to a hospital based program or $40,000 or more to a big university?"
You will probably want to choose an "accredited" nursing program. There are two types of accreditation: one for schools and one for individual educational programs.
For a school to be accredited, its finances, facilities, faculty, and procedures have to have been investigated by an educational standards organization and found to meet those standards. In the U.S., colleges and universities are accredited by one of the regional accreditation organizations recognized by the U.S. Dept. of Education and the Council for Higher Education Accreditation.
For a program to be accredited, its faculty and curriculum have to have been investigated by a professional organization in that field and found to meet its standards for preparing practitioners of the field.
How do you determine the relative reputations of the nursing schools you're interested in? Making sure they have the relevant accreditations is a good start. You can also investigate where the school's faculty have worked, what procedures they've done., and what advancements they've attained. Beyond that, Esther Atwood suggests that you ask about the schools' requirements for admission and graduation, as well as their "pass boards" rate (the percentage of their alumni who have passed their state board licensure exams). And if the school tracks where their alumni are currently working, that can also be revealing.
Decided on a couple of programs you like the looks of? Then apply to them. Most schools will have application forms and directions for submitting them on their Web sites. Schools will want you to provide proof that you graduated from high school or have a GED. Any four year nursing program with limited, competitive admissions will also want a copy of your ACT or SAT scores, several references, (probably) your high school transcripts, and (very probably) an essay in which you tell them why you want to study nursing there and why you'll make a good student. As mentioned earlier, any medical or personal care work or volunteer experience you can cite, no matter how limited or marginal, will be a plus.
In addition to standard college level student grants and loans (such as the Stafford and PLUS loans in the US), a wide variety of scholarships and other aids are available for nursing students; refer to our financial aid page. Dan Cook points out that if you attend a hospital based school, the hospital will often forgive your tuition if you agree to work for the hospital for a few years after you graduate. He adds that it's often possible for a student at a hospital based school to get a low interest loan through the hospital's credit union, if necessary. Even if you didn't get your education from them, many hospitals and other employers offer loan forgiveness to recent graduates who come to work there; according to Esther Atwood, even ACMH (which is not a particularly large hospital) will currently pay off up to $12,000 of loans.
Here are some of the subjects you might learn if you choose to study nursing:
- Some programs will start you out with biology (the science of life) and/or chemistry (the science of matter), perhaps leading to biochemistry (the science of how living things use matter, including the chemicals and chemical reactions occurring in the human body).
- Anatomy will teach you the body's components (bones, muscles, organs, etc.) and physiology will teach you how they function under normal conditions; pathophysiology will teach you how they function (and malfunction) in response to illness or injury.
- Microbiology is the study of the microorganisms that live around, on, and inside us, including both the "good bugs" that are necessary for our health and the "bad bugs" -- bacteria, viruses, parasites, and other pathogens -- that can cause infectious disease.
- Learn nutrition and you'll understand how our diets can help or hinder our health. You'll also get an idea of the special dietary needs of people with various medical conditions.
- In psychology you'll learn about the mind and in sociology you'll learn about societies, including how people's mental states and social environments can contribute to their wellness or illness.
- To work in acute or critical care or in any position that involves evaluation or investigation, it's important to master health assessment, the skill of determining how well or badly a patient is doing and what should be done about it.
- Health care requires careful and assured teamwork; role development assures that you know what role you can perform in a medical team, including which procedures the various licenses legally allow you to do, which tasks RNs can delegate to LPNs or nurses of any kind can delegate to CNAs, etc.
- Some programs will have courses that focus on the different procedures, methods, and strategies involved in care of individuals, care of families, care of community, mental health care, end-of-life care, and so on.
- As in any field with so much potential to impact people's lives for better or worse, ethics is vital in nursing. When you deal with your patients, your coworkers, and the medical system in general, you can't simply do whatever you want, or whatever other people want, or whatever you think they want. Doing the ethically right thing is important for you personally, your patients, and your profession.
- Nursing management highlights how to supervise and manage nursing teams, including how to meet business goals such as improving productivity and reducing costs without sacrificing the quality of patient care.
- If you're an LPN studying to be an RN, an undergraduate RN studying for a BSN, or someone working toward a similar "skill upgrade," many programs suggest or require a course that prepares you for the challenges of that transition.
In addition to these, Sandra Gray recommends that if you're thinking of becoming a school nurse or teaching nurse later in your career, you take the courses you'll need for these specialties during your initial nursing education, before you start a nursing job. If you wait until after you graduate and start working to take these kinds of courses, she warns that "it can be up to four more years, taking a class here and there when you can, to get the credits you need."
To be licensed to practice nursing in the United States, you need to pass one of the license exams administered by the National Council of State Boards of Nursing (NCSBN). To become an RN, you must pass the National Council Licensure Examination for Registered Nurses (NCLEX-RN); to become an LPN or LVN, you must pass the National Council Licensure Examination for Practical Nurses (NCLEX-PN). As mentioned earlier in this article, you'll also need to pass a separate licensing exam to work in many advanced practice nursing fields. You'll need to renew your license(s) periodically; currently RNs in Pennsylvania, for example, have to renew their license once every three years.
Given the current job market for nurses, it probably won't be hard for you to find a position once you graduate and get your license (assuming you don't already have one lined up and waiting for you). However, there are still some things you should have, and can do, to improve your chances.
(Two things you must not have are a criminal record or a drug habit. Esther Atwood mentions that ACMH's pre-employment screening for nurses includes both a physical and a drug test; Dan Cook points out that most nursing positions will also require a background check.)
Work up a good resumé that includes any prior paid or volunteer medical work; positions in some specialties require previous experience. Line up some references, and check the web and your network of friends and family. The nursing field is growing by leaps and bounds, and finding a job should not be difficult, even in recessions.
Nursing is a curious profession; it has the Golden Rule (loosely, "treat others the way you'd want them to treat you") built in. Yes, nursing can be emotionally and possibly monetarily rewarding in the short term, but it also carries the promise of long-term reciprocity: While you're well,as a nurse you can and should do your best for those who are frail or unwell, because someday, if you should become frail or unwell, you have to hope that others will do the same for you. Though a similar circle of "instant karma" also holds between doctors and patients, the relationship isn't as day-to-day or intimate. Of all the common relationships between professions and the people they serve, perhaps only teachers and students share the same kind of close and inevitable interchangeability that nurses and their patients have. So, if you choose, be a good student and then a good nurse; if God or fortune smiles, when your time comes to be a teacher or a patient, you won't be disappointed by those who follow in your footsteps.