Nursing

Nursing

A nurse checks a patient's blood pressure.
Occupation
Activity sectors	Nursing
Description
Competencies	Caring for general and specialized well-being of patients
Education required	Qualifications in terms of statutory regulations according to national, state, or provincial legislation in each country
Fields of employment	Hospital Clinic Laboratory Research Education Home care
Related jobs	Medicine Glossary of medicine

Nursing is a health care profession that "integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence".^[1] Nurses practice in many specialties with varying levels of certification and responsibility. Nurses comprise the largest component of most healthcare environments.^[2][3] Shortages of qualified nurses are found in many countries.^[4]

Nurses develop a plan of care, working collaboratively with physicians, therapists, the patient, the patient's family, and other team members that focuses on treating illness to improve quality of life.

In the United Kingdom and the United States, clinical nurse specialists and nurse practitioners, diagnose health problems and prescribe the correct medications and other therapies, depending on regulations that vary by state.^[5] Nurses may help coordinate care performed by other providers or act independently as nursing professionals. In addition to providing care and support, nurses educate the public and promote health and wellness.^[6]

In the U.S., nurse practitioners are nurses with a graduate degree in advanced practice nursing, and are permitted to prescribe medications. They practice independently in a variety of settings in more than half of the United States. In the postwar period, nurse education has diversified, awarding advanced and specialized credentials, and many traditional regulations and roles are changing.^[7][8]

Nursing historians face challenges of determining whether care provided to the sick or injured in antiquity is called nursing care.^[9] In the fifth century BC, for example, the Hippocratic Collection in places described skilled care and observation of patients by male "attendants," who may have provided care now provided by nurses.^[10] Around 600 BC in India, it is recorded in Sushruta Samhita, Book 3, Chapter V about the role of the nurse as "the different parts or members of the body as mentioned before including the skin, cannot be correctly described by one who is not well versed in anatomy. Hence, anyone desirous of acquiring a thorough knowledge of anatomy should prepare a dead body and carefully, observe, by dissecting it, and examining its different parts."

In the Middle Ages, members of religious orders such as nuns and monks often provided nursing-like care.^[11] Examples exist in Christian,^[12] Islamic,^[13] Buddhist,^[14] and other traditions. Phoebe, mentioned in Romans 16, is described in many sources as "the first visiting nurse".^[15][16] These traditions were influential in the development of the ethos of modern nursing. Its religious roots remain in evidence in many countries. One example in the United Kingdom is the use of the historical title "sister" to refer to a senior nurse.^[17]

During the Reformation, Protestant reformers shut down monasteries and convents, allowing a few hundred municipal hospices to remain in operation in northern Europe. Nuns who had been serving as nurses were given pensions or told to marry and stay home.^[18] Nursing care went to the inexperienced as traditional caretakers, rooted in the Roman Catholic Church, were removed from their positions. The nursing profession in Europe was extinguished for approximately 200 years.^[19]

During the Crimean War, Grand Duchess Elena Pavlovna called for women to join the Order of Exaltation of the Cross (Krestodvizhenskaya Obshchina) for a year of service in military hospitals. The first section of twenty-eight "sisters", headed by Aleksandra Petrovna Stakhovich, the Directress of the Order, reached Crimea early in November 1854.^[20]

Florence Nightingale laid the foundations of professional nursing after the Crimean War,^[22] in light of a comprehensive statistical study she made of sanitation in India, leading her to emphasize the importance of sanitation. "After 10 years of sanitary reform, in 1873, Nightingale reported that mortality among the soldiers in India had declined from 69 to 18 per 1,000".^[23]: 107

Nightingale believed that nursing was a social freedom and mission for women. She believed that any educated woman could help improve the care of the ill.^[24] Her Notes on Nursing (1859) was a popular call to action. The Nightingale model of nursing education led to one of the first schools of nursing to be connected to a hospital and medical school. It spread widely in Europe and North America after 1870.^[25]

Nightingale included five factors that helped nurses in her time who worked amidst poor sanitation and little education. These factors included (1) fresh air, (2) clean water, (3) a working drainage system, (4) cleanliness, and (5) good light. Nightingale believed that a clean working environment was important in caring for patients. In the 19th century, this theory was ideal for helping patients, providing a guide for nurses to alter the environment around the patient for the betterment of their health.^[26]

Nightingale's recommendations built upon the successes of Jamaican "doctresses" such as Mary Seacole, who like Nightingale, served in the Crimean War. Seacole practised hygiene and the use of herbs in healing wounded soldiers and those suffering from diseases in the 19th century in the Crimea, Central America, and Jamaica. Her predecessors had great success as healers in the Colony of Jamaica in the 18th century, and they included Seacole's mother (Mrs. Grant), Sarah Adams, Cubah Cornwallis, and Grace Donne, the mistress and doctress to Jamaica's wealthiest planter, Simon Taylor.^[27]

Other important nurses in the development of the profession include:

• Agnes Hunt from Shropshire was the first orthopedic nurse and was pivotal in the emergence of the orthopedic hospital, the Robert Jones & Agnes Hunt Hospital in Oswestry, Shropshire.
• Valérie de Gasparin opened, with her husband Agénor de Gasparin, the world's first nursing school: La Source, in Lausanne, Switzerland.
• Agnes Jones established a nurse training regime at Brownlow Hill infirmary, Liverpool, in 1865.
• Linda Richards established nursing schools in the United States and Japan, and was officially the first professionally trained nurse in the US, graduating in 1873 from the New England Hospital for Women and Children in Boston.
• Clarissa Harlowe "Clara" Barton was a pioneer American teacher, patent clerk, nurse, and humanitarian, and the founder of the American Red Cross.
• Saint Marianne Cope was a Sister of St. Francis who opened and operated some of the first general hospitals in the United States, instituting cleanliness standards that influenced the development of America's hospital system.^[28]

Red Cross chapters, which began appearing after the establishment of the International Committee of the Red Cross in 1863, offered employment and professionalization opportunities for nurses (despite Nightingale's initial objections).^[29] Catholic orders such as Little Sisters of the Poor, Sisters of Mercy, Sisters of St. Mary, St. Francis Health Services, Inc. and Sisters of Charity built hospitals and provided nursing services during this period.^{[citation needed][30]} The modern deaconess movement began in Germany in 1836.^[31] Within a half century, over 5,000 deaconesses had surfaced in Europe.^[32]

Formal use of nurses in the military began in the latter half of the nineteenth century. Nurses saw active duty in the First Boer War, the Egyptian Campaign (1882),^[33] and the Sudan Campaign (1883).^[34]

In the 19th and early 20th century, nursing was considered a woman's profession, just as doctoring was a profession for men. With increasing expectations of workplace equality during the late 20th century, nursing became an officially gender-neutral profession, though in practice the percentage of male nurses remained well below that of female physicians in the 21st century.^[35][36]

Hospital-based training became standard in the US in the early 1900s, with an emphasis on practical experience. The Nightingale-style school began to disappear. Hospitals and physicians saw women in nursing as a source of free/inexpensive labor. Exploitation of nurses was not uncommon by employers, physicians, and education providers.^[37]

Many nurses saw active duty in World War I, but the profession transformed again during the Second World War. British nurses of the Army Nursing Service were part of every overseas campaign.^[38] More nurses volunteered for service in the US Army and Navy than any other occupation.^[39][40] The Nazis had their own Brown Nurses, numbering 40,000.^[41] Two dozen German Red Cross nurses were awarded the Iron Cross for heroism under fire.^[42]

The development of undergraduate and post-graduate nursing degrees came after the war. Nursing research and a desire for association and organization led to the formation of professional organizations and academic journals. Nursing became recognized as a distinct academic discipline, initially tasked to define the theoretical basis for practice.^[43]

Nurses are perceived to be in short supply around the world, particularly in South East Asia and Africa.^[44] A global survey by McKinsey & Company in 2022 found that between 28% and 38% of nurse respondents in the United States, the United Kingdom, Singapore, Japan, and France said they were likely to leave their role in direct patient care in the next year. The top five factors which they said would make them stay were:

• Safe working environment
• Work-life balance
• Caring and trusting team-mates
• Meaningful work
• Flexible work schedule

Pay ranked eighth on the list.^[45] A 2023 American survey found that ~30% were considering leaving patient care.^[46]

Although nursing practice varies both through its various specialties and countries, these nursing organizations offer the following definitions:

Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well, and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles.

— International Council of Nurses^[47]

The use of clinical judgment in the provision of care to enable people to improve, maintain, or recover health, to cope with health problems, and to achieve the best possible quality of life, whatever their disease or disability, until death.

— Royal College of Nursing (2003) ^[48]

Nursing is the protection, promotion, and optimization of health and abilities; prevention of illness and injury; alleviation of suffering through the diagnosis and treatment of human responses; and advocacy in health care for individuals, families, communities, and populations.

— American Nurses Association^[49]

The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge.

— Virginia Avenel Henderson^[50]

The practice of nursing is based upon a social contract that delineates professional rights and responsibilities as well as accountability mechanisms. In almost all countries, nursing practice is defined and governed by law, and entrance to the profession is regulated at the national or state level.

The nursing community worldwide aims for professional nurses to ensure quality care, while maintaining their credentials, code of ethics, standards, and competencies, and continuing their education.^[47] Multiple educational paths lead to becoming a professional nurse; these vary by jurisdiction; all involve extensive study of nursing theory and practice as well as training in clinical skills.

Nurses provide care based on the individual's physical, emotional, psychological, intellectual, social, and spiritual needs. The profession combines physical science, social science, nursing theory, and technology.

Nurses typically hold one or more formal credentials. Roles and responsibilities follow the level of education. For example, in the United States, Licensed Practical Nurses (LPN) have less education than Registered Nurses (RN) and accordingly, a narrower scope of practice.

In the United States, multiple educational paths qualify a candidate to sit for the licensure examination as an RN. An Associate Degree in Nursing (ADN) is awarded to those who earn a two-year undergraduate degree. This degree is also referred to as an Associate in Nursing (AN), Associate of Applied Science in Nursing (AAS), or Associate of Science in Nursing (ASN).^[51] A Bachelor of Science in Nursing (BSN) is awarded to those who have earned an American four-year academic nursing degree. LPNs and those who complete either an RN education program in the United States are eligible to sit for the National Licensure Examination (NCLEX) test, a standardized exam that they must pass to become licensed.^[52]

Some nurses follow the traditional role of working in a hospital setting. Options there include: pediatrics, neonatal, maternity, OBGYN, geriatrics, orthopedics, medical-surgical, operating room, ambulatory, and nurse anesthetists and informatics (eHealth). Other options include community health, mental health, clinical nursing specialists, and nurse midwives.^[53] RNs may also pursue roles as advanced practice nurses.

Nurses are not doctors' assistants. They may act in that capacity, such as in the emergency department or in trauma care, but more often independently care for their patients or assist other nurses.^[54] RNs treat patients, record their medical history, provide emotional support, and provide follow-up care. Nurses also help doctors perform diagnostic tests.^[55]

As of 2020, in the United States 19.4% of nursing positions are held by people of non-white backgrounds. The remaining 80.6% of positions are held by Caucasians.^[56]

Despite attempts to correct the imbalance, nursing is a female-dominated profession in many countries; according to the WHO's 2020 State of the World's Nursing, approximately 90% of the nursing workforce is female.^[57] For instance, the male-to-female ratio of nurses is approximately 1:19 in Canada and the United States.^[58][59] This ratio is matched in many other countries. Notable exceptions include Francophone Africa, which includes the countries of Benin, Burkina Faso, Cameroon, Chad, Congo, Côte d'Ivoire, the Democratic Republic of Congo, Djibouti, Guinea, Gabon, Mali, Mauritania, Niger, Rwanda, Senegal, and Togo, which all have more male than female nurses.^[60] In Europe, in countries such as Spain, Portugal, Czech Republic and Italy, over 20% of nurses are male.^[60] In the United Kingdom, 11% of nurses and midwives registered with the Nursing and Midwifery Council (NMC) are male.^[61] The number of male nurses in the United States doubled between 1980 and 2000.^[62] On average, male nurses in the US receive more pay than female nurses.^[63]

Nursing practice is the actual provision of nursing care. In providing care, nurses implement a nursing care plan defined using the nursing process. This is based around a specific nursing theory that is selected based on the care setting and the population served. In providing nursing care, the nurse uses both nursing theory and best practice derived from nursing research.^[64] Many nursing theories are in use.^[65] Like other disciplines, the profession has developed multiple theories derived reflecting varying philosophical beliefs and paradigms or worldviews.

In general terms, the nursing process is the method used to assess and diagnose needs, plan outcomes and interventions, implement interventions, and evaluate outcomes. The nursing process as defined by the American Nurses Association is made up of five steps: 1) evaluate, 2) implement, 3) plan, 4) diagnose, and 5) assess.^[65]

Nurses manage and coordinate care to support activities of daily living (ADL). This includes assisting in patient mobility, such as moving an activity intolerant patient within a bed. They often delegate such care to nursing assistants.

Medication management and administration are common hospital nursing roles, although prescribing authority varies across jurisdictions. In many areas, RNs nurses administer and manage medications prescribed by others. Nurses are responsible for evaluating patients throughout their care – including before and after medication administration – adjustments to medications are often made through a collaborative effort between the prescriber and the nurse. Regardless of the prescriber, nurses are legally responsible for the drugs they administer. Legal implications may accompany an error in a prescription, and the nurse may be expected to note and report the error. In the United States, nurses have the right to refuse to administer medication that they deem to be potentially harmful.^[66] Some nurses take additional training that allows them to prescribe medications within their scope of practice.^[67]

Effective patient/family education leads to better outcomes. Nurses explain procedure, recovery, and ongoing care, while helping everyone cope with the medical situation.^[68]

Many times, nurses are busy, leaving little time time to educate patients.^[69]

The patient's family needs similar education.^[69] Educating both the patient and their family increases the chance for a better outcome.^[70]

Nurses have to communicate in a way that can be understood by the patient. Education techniques encompass conversations, visuals, reading materials, and demonstrations.^[68]

Nursing is the most diverse of all health care professions. Nurses practice in a wide range of settings, but generally follows the needs of the patient.

The major specialties are:

• communities/public health
• family/individual care
• adult-gerontology
• pediatrics
• obstetrics
• neonatal
• women's health/gender-related
• mental health
• informatics (eHealth)
• acute care
• ambulatory settings (physician offices, urgent care settings, camps, etc.)
• school/college/institutional infirmaries
• military
• cardiac care
• orthopedic care
• palliative care
• perioperative
• oncology
• telenursing
• radiology
• emergency care

Nurses with additional degrees allow for specialization. Nursing professions can be separated into categories by care type, age, gender, certain age group, practice setting, individually or in combination.^[71]

Nurses practice in a wide range of settings, including hospitals, private homes, schools, and pharmaceutical companies. Nurses work in occupational health settings^[72] (also called industrial health settings), free-standing clinics, physician offices, nurse-led clinics, long-term care facilities and camps. They work on cruise ships, military bases, and in combat settings.

Nurses act as advisers and consultants to the health care and insurance industries. Many nurses also work in health advocacy and patient advocacy, helping in clinical and administrative domains.^[73] Some are attorneys and others work with attorneys as legal nurse consultants, reviewing patient records to assure that adequate care was provided and testifying in court.

Nurses can work on a temporary basis, which involves doing shifts without a contract in a variety of settings, sometimes known as per diem nursing, agency nursing or travel nursing. Nurses work as researchers in laboratories, universities, and research institutions. Nurses work in informatics, acting as consultants to the creation of computerized charting programs and other software. Nurse authors publish articles and books to provide essential reference materials.

The international nursing shortage^[74] is in part due to their work environment. In a recent review of the literature specific to nursing performance, nurses were found to work in generally poor environmental conditions. Some jurisdictions have legislation specifying acceptable nurse-to-patient ratios.

The fast-paced and unpredictable nature of health care places nurses at risk for injuries and illnesses, including high occupational stress. Nurses consistently identify stress as a major work-related concern and have among the highest levels of occupational stress among all professions. This stress is caused by the environment, psychosocial stressors, and the demands of nursing, including mastering new technology, emotional labor, physical labor, shift work, and high workload. This stress puts nurses at risk for short-term and long-term health problems, including sleep disorders, depression, mortality, psychiatric disorders, stress-related illnesses, and overall poor health. Nurses are at risk of developing compassion fatigue and moral distress, which can damage mental health. They have high rates of occupational burnout (40%) and emotional exhaustion (43.2%). Burnout and exhaustion increase the risk for illness, medical error, and suboptimal care provision.^[75]

Healthcare has consistently ranked among the industries with the highest rates of musculoskeletal injuries, largely related to patient handling. Anywhere from 30-70% of reported musculoskeletal injuries are related to patient handling. Nurses are routinely tasked with lifting, repositioning, and mobilizing patients. According to the National Institute for Occupational Safety and Health (NIOSH) the single greatest factor in overexertion injuries is the manual lifting, moving and repositioning of patients.^[76] These tasks present unique ergonomic hazards that results in a high rate of acute and cumulative musculoskeletal injuries.^[77][78]

The most frequently injured body part is the back, with up to 72% of nurses reporting non-specific low back pain.^[79] The US Bureau of Labor Statistics reported that for 2021-2022 the rate of overexertion injuries leading to days away from work for nurses was 45.4 per 10,000 full time employees, while nursing aids came in at 145.5 compared to the average for all industries of 26.1.^[80]

Traditionally, nurses are trained in manual patient handling techniques.^[81] The body of evidence has demonstrated, however, that such interventions are ineffective.^[81]

Nurses are at risk for workplace violence and abuse.^[82] Violence is typically perpetrated by non-staff (e.g. patients or family), whereas abuse is typically is by hospital personnel. In the US in 2011, 57% of nurses reported that they had been threatened at work; 17% were physically assaulted.^[75]

The three types of workplace violence that nurses can experience are: physical violence (hitting, kicking, beating, punching, biting, and using objects);^[83] psychological violence (threats and/or coercion); sexual violence (attempted/completed non-consensual sex act).^[84]

Workplace violence can be in another way: interpersonal violence and organizational coercion. Interpersonal violence is committed by workers and/or patients and their families. Its predominant form is verbal abuse. Organizational coercion may include excessive workloads, mandatory shifts, involuntary placement in another part of the workplace, low salaries, denial of benefits/overtime, poor working environment, and other stressors.^[85] These issues affect quality of life. Managers who lack understanding of the severity of these problems and do not support workers increase worker stress.

Many factors contribute to workplace violence. These factors can be divided into environmental, organizational, and individual psychosocial. The environmental factors can include the specific setting (for example the emergency department), long patient wait times, frequent interruptions, uncertainty regarding the patients' treatment, and heavy workloads.^[86] Organizational factors can include inefficient teamwork, organizational injustice, lack of aggression and/or stress management programs, and distrust between colleagues.^[86] Individual psychosocial factors may include nurses being young and inexperienced, previous experiences with violence, and a lack of communication skills.^[86] Misunderstandings may also occur due to the communication barrier between nurses and patients.^[87] An example of this could be the patient's condition being affected by medication, pain, and/or anxiety.

Workplace violence has many causes. The most common perpetrators for harassment and/or bullying against nursing students were registered nurses including preceptors, mentors, and clinical facilitators.^[87] However, the main perpetrators of workplace violence against nurses were patients. 80% of serious violent incidents in health care centers were by patients.

Workplace violence has many effects. It has negative emotional and physical impacts on nurses. They feel depersonalized, dehumanized, worn out, and stressed out.^[88] Nurses have reported burn-out due to frequent exposure to this violence.

Interventions can mitigate these occupational hazards. They can be individual-focused or organization-focused. Individual-focused interventions include stress management programs, which can be customized to individuals. Stress management programs can reduce anxiety, sleep disorders, and other symptoms of stress. Organizational interventions focus on reducing stressful aspects of the work environment by identifying stress generators and developing solutions to them. Combining organizational and individual interventions is most effective at reducing stress.^[75] In some Japanese hospitals, powered exoskeletons are used to reduce physical loads.^[89] Lumbar supports (i.e. back belts) have been trialed.^[90]

In the US, scope of practice is determined by the licensing state or territory. Each has its own laws, rules, and regulations governing licensing and care. Usually a board of nursing makes rules and regulations and handles administration of these rules for the jurisdiction.

RNs are employed by physicians, attorneys, insurance companies, governmental agencies, community/public health agencies, private industry, school districts, ambulatory surgery centers, device or pharmaceutical manufacturers, or chemical companies. Some work as independent consultants. Research nurses conduct or assist in research or evaluation in areas such as biology, psychology, human development, and health care systems.

Many employers offer flexible work schedules, child care, educational benefits, and bonuses. About 21 percent of registered nurses are union members or covered by union contract.^[91]

Nursing is the nation's largest health care profession. As of 2023, 3,175,390 registered nurses were employed, paid a median income of $86,070.^[92]

The primary pathway to professional nursing is the four-year Bachelor of Science in nursing (BSN) degree. Registered nurses are prepared either through a BSN program; a three-year associate degree in nursing; or a three-year hospital training program, receiving a hospital diploma. All take the same licensing exam. The number of diploma programs has declined steadily—to less than 10 percent of all basic RN education programs—as nursing education has shifted from hospital-operated instruction into the college and university system.

Nursing schools may be accredited by either the Accreditation Commission for Education in Nursing (ACEN) or the Commission on Collegiate Nursing Education (CCNE).

Controversy exists over the appropriate entry-level preparation of RNs. Some professional organizations believe the BSN should be the sole method of RN preparation and ADN graduates should be licensed as "technical nurses" to work under the supervision of BSN graduates. Others feel the on-the-job experiences of diploma and ADN graduates makes up for any deficiency in theoretical preparation.^{[citation needed]}

The oldest method of nursing education is the hospital-based diploma program, which lasts approximately three years. Students take between 30 and 60 credit hours in anatomy, physiology, microbiology, nutrition, chemistry, and other subjects at a college or university, then move on to intensive nursing classes. Until 1996, most RNs in the US were initially educated in nursing by diploma programs.^[93] According to the Health Services Resources Administration's 2000 Survey of Nurses only six percent of nurses who graduated from nursing programs received their education at a Diploma School of Nursing.^[94]

The most common initial nursing education is a two-year Associate Degree in Nursing (ADN, or Associate of Applied Science in Nursing, Associate of Science in nursing, Associate Degree in Nursing), a two-year college degree. Some four-year schools offer the ADN. Associate degree nursing programs have prerequisite and corequisite courses (which may include English, Math and Human Anatomy and Physiology) and consume three years or longer.

Another pathway into the profession is to obtain a Bachelor of Science in Nursing (BSN), a four-year degree that also prepares nurses for graduate-level education. For the first two years, students complete general education requirements along with nursing courses. In some new programs an active LPN license can replace the first two years of nursing classes. Advocates for ADN and diploma programs claim that such programs take an on-the-job training approach, and that the BSN should remain an academic degree that emphasizes research and nursing theory. Some states require a specific amount of clinical experience that is the same for both BSN and ADN students. A BSN degree qualifies its holder for administrative, research, consulting and teaching positions not typically available to ADN holders, but is not necessary for most patient care functions.

Advanced education in nursing includes master's and doctoral degrees. Graduate education prepares the graduate for specialization as an advanced practice registered nurse (APRN) or for advanced roles in leadership, management, or education. The clinical nurse leader (CNL) is an advanced generalist who focuses on the improvement of quality and safety outcomes for patients or patient populations from an administrative and staff management focus.

Doctoral programs prepare the student for work in nursing education, health care administration, clinical research, public policy, or advanced clinical practice. Most programs confer the PhD in nursing or Doctor of Nursing Practice (DNP).

Areas of advanced nursing practice include that of a nurse practitioner (NP), a certified nurse midwife (CNM), a certified registered nurse anesthetist (CRNA), or a clinical nurse specialist (CNS). Nurse practitioners and CNSs work assessing, diagnosing and treating patients in fields as diverse as family practice, women's health care, emergency nursing, acute/critical care, psychiatry, geriatrics, or pediatrics, additionally, a CNS usually works for a facility to improve patient care, do research, or as a staff educator.

Completion of any one of these three educational routes allows a graduate nurse to take the NCLEX-RN, the test for licensure as a registered nurse. This test is accepted nationwide as an indicator of competency.

It has been reported^{[by whom?]} that the number of new graduates and foreign-trained nurses is insufficient to meet the demand for registered nurses; this is often referred to as the nursing shortage. One study reported that the nursing shortage is voluntary,^{[95] [citation needed]} caused by nurses voluntarily leaving the profession. In 2006 it was estimated that approximately 1.8 million licensed nurses chose not to work as a nurse. The Bureau of Labor Statistics (BLS) estimated that by 2020, 1.2 million nursing job openings would be available.^[96]

Professional nursing certification boards offer voluntary certification exams to demonstrate clinical competency in particular specialties. Completion of prerequisites enables an RN to register for an examination, and passage gives an RN permission to use a corresponding professional designation. For example, passage of the American Association of Critical-care Nurses specialty exam allows a nurse to use the initials CCRN.

The American Nurses Credentialing Center (ANCC) is the largest nursing credentialing organization and administers more than 30 specialty examinations.^[97]

Continuing education classes and programs enable nurses to provide the best possible care to patients, advance nursing careers, and keep up with certification requirements. ANCC ensures nurses have access to quality continuing education offerings. Continuing education classes are calibrated to educate all levels of nurses. Many States require continuing education. Nursing licensing boards typically accept courses provided by organizations accredited by other licensing boards, by the ANCC, or its designees.^[98] The National Healthcare Institute maintains a list of continuing education requirements.^{[99][100][101]}

The United States needs many correctional nurses to provide proper health-care to inmates, including mental health treatments.

Correctional health care encompasses LPNS, RNs, nurse practitioners, doctors, pharmacists, therapists, and specialists.^[102]

Upon an inmate's arrival, nurses perform a basic checkup. They can discover existing conditions. Issues including chronic medical conditions, mental health, infectious disease, and substance abuse. Correctional nurses must follow stricter protocols than in a hospital due to confidentiality. Assessing a patient can be difficult. A deputy or officer may have to be present during exams, which can discomfort the patient, compromising the information provided.^[102]

Canadian nursing dates back to 1639 in Quebec, launched by Augustine nuns.^[103] These nuns were trying to open a mission that cared for people's spiritual and physical needs. This mission created the first nursing apprenticeship program in North America.^[103] In the nineteenth century, some Catholic nursing orders were trying to spread their message across Canada. Most nurses were female and had only occasional consultation with a physician. Towards the end of the nineteenth century, hospital care and medical services improved and expanded. Much of this was due to Nightingale's influence. In 1874 the first formal nursing training program was started at the General and Marine Hospital in St. Catharines in Ontario.^[103]

All Canadian nurses and prospective nurses are encouraged by the Canadian Nurses Association to complete a bachelor's degree. All Canadian provinces and territories, with the exception of the Yukon and Quebec, require that all nurses have a bachelor's degree.^[103] The length of time typically required to obtain this degree is four years. However, some Canadian universities offer a two year alternative.^[103]

Nursing specialty certification is available through the Canadian Nurses Association in 22 practice areas,^[103] including:

• cardiovascular nursing
• community health nursing
• critical care nursing
• pediatric critical care nursing
• emergency nursing
• gastroenterology nursing
• gerontological nursing
• hospice palliative care nursing
• medical-surgical nursing
• neonatal nursing
• nephrology nursing
• neuroscience nursing
• occupational health nursing
• oncology nursing
• orthopedic nursing
• pediatric nursing
• peri-anesthesia nursing
• obstetrical nursing
• peri-operative nursing
• psychiatric and mental health nursing
• rehabilitation nursing
• Wound, ostomy, and continence nursing

Nursing specialty certification generally requires practice, experience, and passing a test based on competencies for a specific medical or surgical domain.

Latin American nursing is based on three levels of training: (a) professional/registered, (b) technical, and (c) auxiliary.^[104] Nursing education in Latin America and the Caribbean includes the principles and values of universal health and primary health care. These principles are based on critical and complex thinking development, problem-solving, evidence-based clinical decision-making, and lifelong learning.^[105][106]

To practice lawfully as a registered nurse, the practitioner must hold a valid registration with the Nursing and Midwifery Council.^[108] From April 2016, nurses in the United Kingdom are expected to revalidate every three years by providing evidence of further development and active practice.^[109][110]

First-level nurses make up the bulk of the registered nurses in the UK. Titles include Registered Nurse Adult (RNA), Registered Nurse Child (RNC), Registered Nurse Mental Health (RNMH), and Registered Nurse (of) Learning Disabilities (RNLD). Second-level nurse training is no longer provided; however, such earlier-certified nurses are able to practice in the United Kingdom as a registered nurse. Most refer to themselves as Enrolled Nurses (ENs) or State Enrolled Nurses (SENs).

• Nurse practitioners – Most of these nurses obtain a minimum of a master's degree and a desired post grad certificate. They typically perform roles similar to those of physicians and physician assistants. They can prescribe medications as independent or supplementary prescribers, although they are still regulated, unlike physician's assistants. Most Nurse Practitioners (NPs) have referral and admission rights to hospital specialties. They commonly work in primary care (e.g. General Practitioner (GP) surgeries), Accident and Emergency (A&E) departments, or pediatrics although they increasingly practicein other areas. In the UK, the title "nurse practitioner" is legally protected.
• Specialist community public health nurses – traditionally district nurses and health visitors, this group oversees research and publication activities.
• Lecturer-practitioners (also practice education facilitators) – work in the National Health Service (NHS), and in universities. They typically work 2–3 days per week in each setting. In university, they train pre-registration student nurses and often teach specialist courses for post-registration nurses.
• Lecturers – these nurses work full-time in universities, teaching and performing research.

Many nurses who have substantial experience in clinical settings join the ranks of NHS management. This used to be seen as a natural career progression for ward managers positions, however with the advent of specialist nursing roles, this has become a less attractive option.

Nonetheless, many nurses fill positions in the senior management structure of NHS organizations, some even as board members. Others choose to stay a little closer to their clinical roots by becoming clinical nurse managers or modern matrons.

To become a registered nurse, one must complete a program recognised by the Nursing and Midwifery Council (NMC). This involves completing a degree in a branch specialty, leading to an academic award and professional registration as a 1st level registered nurse. Such a course is a 50/50 split of learning in university (i.e. through lectures, assignments and examinations) and in practice (i.e. supervised activities within a hospital or community setting).

These courses take three-four years. The first year is the common foundation program (CFP), which teaches basic knowledge and skills required of all nurses. Skills include communication, taking observations, administering medication, and providing personal care. The remainder of the program consists of training specific to the student's chosen branch of nursing. These are:

• Child nursing
• Mental health nursing
• Learning disabilities nursing

All new qualifying nurses must hold a degree.^[111] However, those nurses who hold a nursing diploma or a certificate are able to continue to practice.

Midwifery training is similar in length and structure, but is sufficiently different that it is not considered a branch of nursing. 18-month programs allow nurses already qualified in the adult branch to hold dual registration as a nurse and a midwife. Courses lasting 2 years allow graduates of other disciplines to train as nurses. This is achieved by more intense study and a shortening of the common foundation program.^[112]

Student nurses in England and Wales can apply for a bursary from the government to support them during their nurse training, and may be eligible for a loan.^[113] Student nurses in Scotland receive a standard bursary that is not means tested, and their tuition fees continue to be paid – however, they are not eligible for loans.

After initial registration, nurses periodically update their skills and knowledge. The Nursing and Midwifery Council requires a minimum of 35 hours of education every three years, as part of its post registration education and practice (PREP) requirements.^[114]

Nurses can develop additional clinical skills after qualification. Cannulation, venipuncture, intravenous drug therapy and male catheterization are the most common among many others.

Many nurses who qualified with a diploma choose to upgrade their qualification to a degree via additional study. Many nurses prefer this to completing a degree initially, as nurses can study in a specialist field as a part of the degree. Financially, in England, it was more lucrative, as diploma students get the full bursary during their initial training, and employers often pay for the degree course as well as the nurse's salary.^[115]

To become specialist nurses (such as nurse consultants, nurse practitioners etc.) or nurse educators, some nurses undertake further training above bachelor's degree level. Master's degrees exist in various healthcare related topics, and some nurses choose to study for PhDs or other higher academic awards. District nurses and health visitors are also considered specialist nurses, and to become such they must undertake specialist training. This is a one-year full-time degree.

All newly qualifying district nurses and health visitors are trained to prescribe from the Nurse Prescribers' Formulary, a list of medications and dressings typically useful to those carrying out these roles. Many of these (and other) nurses will also undertake training in independent and supplementary prescribing, which allows them (as of 1 May 2006) to prescribe almost any drug in the British National Formulary. This has been the cause of a great deal of debate in both medical and nursing circles.^[116]

In the European Union, the profession of nurse is regulated. A profession is said to be regulated when access and exercise is subject to the possession of a specific professional qualification. The regulated professions database contains a list of regulated professions for nurse^[117] in the European Union (EU) member states, European Economic Area (EEA) countries, and Switzerland. This list is covered by the Directive 2005/36/EC.

Nursing education is governed in India by the central body Indian Nursing Council and its norms are implemented through respective State Nursing councils. The list of state nursing councils are available in the official web page of Indian Nursing Council. First formal education in nursing was offered in Madras Medical college, in Madras presidency. Indian Nursing Council Act, 1947. Act Year Number: Act No. 19 of December enactment Date of enactment: [31 December 19act] Act Objective: An Act to constitute the Nursing Council of India. To establish uniform standards of training for nurses, midwives, and health visitors. It is implemented with 17 sections and each section indicates the specific legislative role of the council.

The nursing profession was dominated by females in the British colonial period, but in Madras Presidency, men were actively engaged in the profession.^[118]

Nurses in Israel have a wide variety of responsibilities, including hospital care, patient education, wound care, prenatal and other monitoring, midwifery, and well-baby clinics.

Nursing in Israeli Jewish culture traces its origins to Shifra and Puah, two Hebrew midwives depicted in the Book of Exodus helping women in ancient Egypt give birth and keep their infants safe.

Modern-day nursing was established by nurses sent to Mandatory Palestine and later Israel by the Hadassah organization, as well as a nursing school founded by Henrietta Szold in 1918. During those times, the United Kingdom regulated midwifery in Mandatory Palestine, but the nurses were not mentioned in the regulation decree.

Today, nurses and midwives are regulated by the Israeli Ministry of Health.

Nursing was not an established part of Japan's healthcare system until 1899 with the Midwives Ordinance.^[119] From there the Registered Nurse Ordinance came into play in 1915. This established a legal substantiation to registered nurses all over Japan. A new law geared towards nurses was created during World War II: the Public Health Nurse, Midwife and Nurse Law, established in 1948.^[103] It established educational requirements, standards and licensure. There has been a continued effort to improve nursing in Japan. In 1992 the Nursing Human Resource Law was passed.^[103] This law created the development of new university programs for nurses. Those programs were designed to raise the education level of the nurses so that they could be better suited for taking care of the public.

Japan only recognizes four types of nursing and they are Public Health Nursing, Midwifery, Registered Nursing and Assistant Nursing.

This type of nursing is designed to help the public and is also driven by the public's needs. The goals of public health nurses are to monitor the spread of disease, keep vigilant watch for environmental hazards, educate the community on how to care for and treat themselves, and train for community disasters.

Nurses that are involved with midwifery are independent of any organization. A midwife takes care of a pregnant woman during labour and postpartum. They assist with things like breastfeeding and caring for the child.

Nursing assistants, also known as nurse assistants or CNAs (Certified Nursing Assistants), assist patients with basic daily tasks. Individuals who are assistant nurses follow orders from a registered nurse. They report back to the licensed nurse about a patient's condition. Assistant nurses are always supervised by a licensed registered nurse.

In 1952 Japan established the first nursing university in the country.^[103] An associate degree was the only level of certification for years. Soon people began to want nursing degrees at a higher level of education. Soon the Bachelor's Degree in Nursing (BSN) was established. Currently, Japan offers doctorate-level degrees of nursing in a good number of its universities.

There are three ways that an individual could become a registered nurse in Japan. After obtaining a high school degree the person could go to a nursing university for four years and earn a bachelor's degree, go to a junior nursing college for three years or go to a nursing school for three years.^[103] Regardless of where the individual attends school they must take the national exam. Those who attended a nursing university have a bit of an advantage over those who went to a nursing school. They can take the national exam to be a registered nurse, public health nurse or midwife. In the cases of becoming a midwife or a public health nurse, the student must take a one-year course in their desired field after attending a nursing university and passing the national exam to become a registered nurse. The nursing universities are the best route for someone who wants to become a nurse in Japan.^[103] They offer a wider range of general education classes and they also allow for a more rigid teaching style of nursing. These nursing universities train their students to be able to make critical and educated decisions when they are out in the field. Physicians are the ones who are teaching the potential nurses because there are not enough available nurses to teach students. This increases the dominance that physicians have over nurses.

Students that attend a nursing college or just a nursing school receive the same degree as one who graduated from a nursing university would, but they do not have the same educational background. The classes offered at nursing colleges and nursing schools are focused on more practical aspects of nursing. These institutions do not offer many general education classes, so students who attend these schools will solely be focusing on their nursing educations while they are in school. Students who attend a nursing college or school do have the opportunity to become a midwife or a public health nurse. They have to go through a training institute for their desired field after graduating from the nursing school or college.^[103] Japanese nurses never have to renew their licenses. Once they have passed their exam, they have their license for life.^[103]

Like the United States, Japan is in need of more nurses. The driving force behind this need is the fact that country is aging and needs more medical care for its people. However, the number of available nurses does not seem to be increasing. Nurses face poor working conditions and low social status, and there is a cultural idea that married women quit their jobs for family responsibilities.^[120] On average, Japanese nurses make around 280,000 yen a month, and it is one of the higher paying jobs. However, physicians make twice as much as nurses.^[121] Similar to other cultures, the Japanese people view nurses as subservient to physicians. According to the American Nurses Association article on Japan, "nursing work has been described using negative terminology such as 'hard, dirty, dangerous, low salary, few holidays, minimal chance of marriage and family, and poor image.'"

There are organizations that unite Japanese nurses like the Japanese Nursing Association (JNA); the JNA is a professional organization and not a union. Members of the JNA lobby politicians and produces publications about nursing. According to the American Nurses Association's article on Japan, the JNA "works toward the improvement in nursing practice through many activities including the development of a policy research group to influence policy development, a code of ethics for nurses, and standards of nursing practice." The JNA also provides certification for specialists in mental health, oncology and community health.^[103] There are other organizations, including some that categorize nurses by specialty, like emergency nursing or disaster nursing. One of the older unions that relates to nursing is the Japanese Federation of Medical Workers Union, which was created in 1957.^[103] It is a union that includes physicians as well as nurses. This organization was involved with the Nursing Human Resource Law.^[103]

Philippines is well known for migrant nurses working in other countries especially in the west like the United States of America. It accounts a quarter of overseas nurses in the world. Every year, around 20,000 nurses leave the Philippines to work in more developed countries looking for better pay.^[122] Nurses in the Philippines must be licensed by the Professional Regulatory Commission.

In Taiwan, the Ministry of Health and Welfare is in charge of the regulation of nursing.^[123] The Taiwan Union of Nurses Association (TUNA) is the union unit in Taiwan, fighting for nurses on payment and working time issues.^[124]

Catholic religious institutes were influential in the development of Australian nursing, founding many of Australia's hospitals – the Irish Sisters of Charity were first to arrive in 1838 and established St Vincent's Hospital, Sydney in 1857 as a free hospital for the poor. They and other orders like the Sisters of Mercy, and in aged care the Sisters of the Little Company of Mary and Little Sisters of the Poor founded hospitals, hospices, research institutes and aged care facilities around Australia.^[125][126]

A census in the 1800s found several hundred nurses working in Western Australia during the colonial period of history, this included Aboriginal female servants who cared for the infirm.^[127]

The state nursing licensing bodies amalgamated in Australia in 2011 under the federal body AHPRA (Australian Health Practitioner Registration Authority).^[128] Several divisions of nursing license is available and recognized around the country.

• Enrolled nurses may initiate some oral medication orders with a specific competency now included in national curricula but variable in application by agency.
• Registered nurses hold a university degree (enrolled nurses can progress to registered nurse status and do get credit for previous study).
• Nurse practitioners have started emerging from postgraduate programs and work in both private practice and public hospitals and clinics.
• Mental health nurses must complete further training as advanced mental health practitioners in order to administer client referrals under the Mental Health Act.

Australia enjoys the luxury of a national curriculum for vocational nurses, trained at Technical and Further Education (TAFE) colleges or private Registered Training Organization (RTO). Enrolled and registered nurses are identified by the department of immigration as an occupational area of need, although registered nurses are always in shorter supply, and this increases in proportion with specialization.

^[129]

In 1986 there were a number of rolling industrial actions around the country, culminating when five thousand Victorian nurses went on strike for eighteen days. The hospitals were able to function by hiring casual staff from each other's striking members, but the increased cost forced a decision in the nurses' favor.

The early 2010s saw the emergence of digital health platforms that connect nurses and nurse assistants with vacant job openings in healthcare facilities like skilled nursing homes, home health agencies, and hospitals. They commonly use an app to facilitate communication and allow nurses to find flexible work opportunities based on their preferences. Healthcare partners and facilities benefit from access to a qualified pool of nurses to fill staff shortages quickly and efficiently.^[130] They now compete with large, traditional staffing agencies. In 2017, the National Health Service in the United Kingdom had begun trialling an app for nurses, for short-term placements.^[131]

Some online healthcare staffing platforms, such as United States-based ConnectRN, Nomad Health, Gale Healthcare solutions or Lantum go beyond simply connecting nurses with jobs. They aim to couple staffing applications with fostering a community for nurses, offering resources, career development tools, and networking opportunities.^[132]

Florence Nightingale's seminal epidemiological study, examining mortality among British soldiers during the Crimean War had been published in 1858,^[133] but with the exception of her works, nursing was largely transferred as an oral tradition until the mid 20th century. The inaugural issue of Nursing Research, the first scientific journal specialized in nursing, was released in 1952. During the 1960s, there was an increased interest in attaining PhDs among nurses in the US, but nursing science was still a fledgling area of research, with only a few journals in print until the 1970s.^[134] It has been increasingly argued that nursing research is a sub-discipline in its own right, although there is no prevailing definition of its distinct nature, and many scholars do not attempt giving one.^[135] The question is further complicated by the numerous interpretations of what the defining nature of nursing itself is.^[136][137]

The need to integrate up-to-date scientific evidence into clinical practice, in order to achieve quality care has been increasingly recognized.^[138] This does not preclude the application of personal expertise, as well as adapting to the wants and needs of the client, especially in cases where scientific evidence is sparse, or not applicable to the specific situation.^[139] Common barriers to the study and integration of research findings into clinical decision making include: a lack of opportunity due to demanding working conditions, inexperience in assessing scientific material, and the rapid accumulation of new evidence.^[137]

According to the traditional interpretation physicians are concerned with curing or treating medical conditions, while nurses focus on care. In healthcare settings this line is often blurred, and a more acute difference would be how nurses work in close proximity to their patients for longer periods of time.^[140]

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