Working as a Registered Nurse (RN)
Registered Nurses (RN) have completed at least an Associate's Degree in Nursing and are now licensed by the State to practice nursing. However, many hospitals and healthcare facilities prefer a BSN; this is one of the reason why the RN to BSN program has become so popular for current working nurses. Following the State's Scope of Practice and completing an internship program will ensure the RN is on his or her way to a successful career. But exactly what to RN's do and where do they work?
A standard set of skills is learned in nursing school and every RN knows how to do these certain things upon graduation. The school, and once licensed, the State, feels confident in the nurse's ability to perform these tasks. Upon graduation and passing the NCLEX-RN exam every registered nurse is expected to be proficient and comfortable with these skills.
Standard skills sets include, but are not limited to:
- Administering and monitoring medications
- Inserting, managing, and discontinuing intravenous catheters and intraurethral catheters
- Developing a plan of care for each patient
- Proper assessment and management of all patient populations with appropriate intervention
- Take vital signs, recognize and address abnormalities
- Admitting and discharging a patient safely and appropriately
- Accurate documentation
- Safe patient transfers into and out of bed and chair
- Perform basic life support (BLS)
- Wound care
- Feeding, dressing, and performing hygiene
- Ensuring patient safety, commonly known as ‘do no harm,' or nonmaleficence, which is the cardinal rule of nursing
No matter which specialty the nurse chooses the standard skills learned in nursing school will be used in just about every healthcare setting. Interning at a facility and learning a new specialty will require the nurse to add to this standard skill set and broaden his or her repertoire of knowledge and skills.
An integral part of the healthcare team, the registered nurse ensures that each patient receives direct care that is conducted within the standards of care and hospital policies. While jobs do vary from clinic to clinic, most tasks that an RN is asked to perform will look like this:
*Please note that every RN must have an active nursing license in good standing for the state in which they reside and practice. Licensure is the first step in a lifelong and satisfying professional career path in healthcare.
- Performs nursing visits within scope of practice and assists with developing group visits with manager and providers.
- Demonstrates the appropriate knowledge and skills to coordinate and evaluate patient care
- Works proactively as part of a team with physicians, professionals and staff members
- Exhibits ethical practice with policies and procedures in nursing care at all times
- Is adept at integrating and enforcing regulatory requirements in relation to nursing
- Is able to record and maintain appropriate documentation for records keeping practices
- Is able to follow physician's written orders
- Arranges further medical attention as required by patients and advocates
- Maintains patient confidentiality while develop professional and positive relationships with patients, advocates and family members
- Is committed to professional development, including current practices for OSHA and seclusion and restraint training
- Possesses adequate computer experience to complete daily duties as well as process health records
- Coordinates critical results in a timely manner
- Can interpret documents at a high level of accuracy
- Possesses excellent communication skills
A senior registered nurse often has an expanded scope of duties or an administrative role as a charge nurse, nurse midwife, nurse practitioner, or other APRN specialty. All the roles require an RN license in good standing as well as several years' experience, extended schooling and professional development to meet the requirements of the role and manage reporting staff. Jobs vary between jurisdictions and venues but a senior RN will likely encounter the following tasks in their job:
- Provides oversight to medical assistants and ADNs to ensure patient care
- Attends meetings, prepares reports, and assists in case management
- Manages staff workloads; adjusts staffing to meet patient need
- Mentors others in safe nursing patient care
- Serves as a consultant, advocate and intermediary for patients, caregivers and hospital staff
- Is an intuitive and experienced manager of chronic care conditions who puts forth evidence-based solutions
- Manages a variety of concurrent programs and projects effectively
- Models use of time, equipment and supplies to colleagues and patients for maximum effectiveness
- Guides staff to perform procedures as per the patient care framework
- Promotes progressive learning and development as well as proactive and positive knowledge transfer.
- Takes a proactive leadership role to resolve patient and family situations when consulted by junior nurses or staff
- Creates processes and with authority, assigns them to teams and individuals
- Is a model for delivery of care and excellence in customer service
- Experience with quality improvement or standards activities is preferred.
- Demonstrates an ability to use computer technology to capture, manage, analyze, report, and present data.
- Has excellent analytical and problem solving abilities.
- Has an understanding of health administration database processes and structures
- Is able to work effectively under pressure and with deadlines
The Registered Nurse, or RN, is required to follow the Scope of Practice as mandated by each state. The nursing Scope of Practice is defined by the American Nurses Association (ANA) as, "the ‘who,' ‘what,' ‘where,' ‘when,' and ‘how' of nursing." It provides a legal definition of what nurses can and cannot do, legally.
Once the RN passes the NCLEX-RN and accepts licensure in a state he or she agrees to follow the Scope of Practice for that state. This is a legal and ethical requirement and the RN is held, by the State, to this standard. This is important because of the many areas of nursing and the many types of employers a RN may have.
The RN is covered, legally, by the state's Scope of Practice and not necessarily by the job description or employer policies and procedures. These may hold up to some extent in a court of law but it is generally understood that the Scope of Practice is the standard for nurses. No policy or procedure should ask nurse to step outside of the state's Scope of Practice.
Once the RN specializes in a certain area, such as, aesthetic nursing, the ANA in conjunction with each specialty organization offers resources to promote understanding of the individual Scope of Practice. Certification in a specialty area is a way to further the RNs legal responsibilities as each certification has it's own Scope of Practice. It ensures competency in a new skill set to which the RN is now legally held.
For example, an inexperienced new graduate RN is not allowed, by state Scope of Practice, to perform laser hair removal. This makes sense because the new graduate RN has had no training in school to perform this task. But if the RN is hired by laser hair removal clinic, trained, and certified to perform this task, he or she is now covered by the Scope of Practice to perform this skill. Additionally, the general skill set of nonmaleficence is promoted because it ensures that an inexperienced RN without any training will not be performing laser hair removal on a patient, hence, doing ‘no harm.'
Another example, the new graduate would not be qualified to monitor a patient with an Intraventricular Device, which are placed for patients with traumatic brain injuries, because the RN has had no training with such devices and is not competent in this skill directly out of school. But once the RN is hired and trained to monitor a patient with this device he or she is now covered under the Scope of Practice. Later, the employer may require certification to promote learning and hold the RN to the high-standard of that certifying body, the American Association of Critical Care Nurses.
These are two examples of employers for registered nurses, but where else can RNs work?
How Is Scope of Practice Determined for Nurses?
Each state's Nurse Practice Act (NPA) is determined through the Boards of Nursing. As states are responsible to protect the public, nurse boards are charged with ensuring nurses practice within defined laws of practice.
Ignorance of the law is not an excuse to not follow the Nurse Practice Act. Nurses are responsible to know the details of the NPA in the states where they practice. Nurses can be held accountable when they, even mistakenly, violate NPA standards. For example, certain states require a nurse to report a driving while under the influence (DUI) violation. If not reported to the Board of Nursing, a nurse may face disciplinary action through the board.
Each state's NPA is governed and enacted by that state's legislature. Because the NPA is not detailed or sufficient enough to stand alone, the boards of nursing were created to further define and interpret laws around the NPA. Each Board of Nursing (BON) may enact more stringent laws related to the NPA, but may not go beyond the boundaries of the act. Each BON reports to the National Council of State Boards of Nursing (NCSBN) who oversees the laws and standards.
According to the NCSBN, each state's Nurse Practice Act language must include:
- Authority, power, and composition of a state nursing board
- Education program standards
- Standards and scope of nursing practice
- Types and titles of licenses
- Requirements for licensure
- Grounds for disciplinary action, other violations, and remediation
The NCSB collaborates with many nursing authorities to set, revise, and define nursing practice. The American Association of Colleges of Nursing (AACN), the American Nurse Association (ANA), the American Organization of Nurse Executives (AONE), and the National League for Nursing (NLN) are some of the major players used to interpret regulations and determine standards of care.
A Standard of Care is different than a Scope of Practice. Standard of Care refers to care that is performed in consistence with other nurses of similar education, competency, and experience. Nursing practice and standards of care are often referenced together. For example, professional organizations such as the American Nursing Association publish authoritative statement documents, by interpreting the NPA and Standards of Practice, to define the overall practice of nursing.
As the practice of nursing requires knowledge, skill, and autonomous decision making, the Nurse Practice Act is the law that governs those decisions to protect the community from harm. Nurses are expected to know the NPA for the state in which they practice. The NCSB's Scope of Practice Decision-Making Framework tool is a useful tool nurses can utilize to determine nursing practice responsibilities.
Choosing which degree program to pursue to become a registered nurse can be challenging. An associate's degree is the minimal degree required to work as an RN. For the most part, community colleges offer ADN degrees. Choosing the ADN route might be a desirable choice due to:
- Cost - Vocational schools and community colleges offer ADN programs and tend to be less expensive than four-year universities
- Time - Typically, ADN programs are considered "two-year" programs. This benefits those who hope to get out into the workforce as soon as possible. Vocational schools sometimes have "fast-track" ADN programs that allow students to attend school year-round, while other schools have winter or summer breaks.
- Personal Goals - Many student nurses are content working as bedside nurses, and not necessarily wanting to pursue advanced-degree nursing or management, which would require a BSN to start. Or, the student may hope to become an advanced-practice nurse, manager, or educator, but wishes to get started as soon as possible to build clinical skills and pursue a higher degree later.
Students who choose the BSN route can expect to spend around four years in school. Four-year universities also tend to have a higher tuition cost. However, students may choose the BSN path if:
- They are unsure if they'd like to pursue a higher degree at some point, but would like to earn a BSN to shorten future educational paths
- They ultimately would like to get into management, education, administration, or research
ADN vs. BSN is a topic many nursing students wonder about when choosing a program. There is no definitive answer as to which is "better," as organizations differ in their requirements. RN positions will usually state which degree is the minimum requirement, and some may indicate a "BSN is preferred." Some organizations will hire ADN nurses, but require them to obtain a BSN after hire. Some will also assist with the cost of a BSN program. Today, RN to BSN programs are quite common and make obtaining higher nursing education easier than ever. Students are encouraged to research nearby organizations to identify the hiring requirements for RNs.
As far as clinical ability, many would argue there is no difference between an ADN nurse and BSN nurse who are performing the same bedside-nurse job. However, some would say that BSN nurses are more efficient, well-rounded, and better prepared for the RN role. These perceptions are difficult to prove, as they are subjective. Many ADN nurses can work circles around BSN nurses, and vice-versa-it depends on the nurse.
Whether a student chooses an ADN or a BSN program, it's important to recognize which is in demand in their nearby facilities or organizations that they hope to work for. It's also essential to ensure that whichever degree they decide to pursue is earned from an accredited institution.
For now, yes. The demand for registered nurses is very high and healthcare facilities need ADN-educated nurses to fill the demand.
However, the nursing shortage has been in effect for years, and to help fill the void, a call for more nurses to enter the field has been heard and responded to in massive numbers. Many, many nursing students have completed nursing programs and have entered the field of nursing, and many more are in the process of doing so. This is creating a shift for the hiring managers of healthcare facilities.
Healthcare facilities are now privileged to have a large number of qualified registered nurses to interview and hire. This allows managers to be more selective and choose candidates who have higher levels of education or a strong desire to earn a Bachelor's degree within a few years of employment. In addition to this, many healthcare organizations are beginning to use the BSN as a minimum qualification for the RNs they hire. In short, ADN-educated RNs are absolutely able to find jobs in the field, but they may find employment options more limited than their BSN-educated counterparts, and this may become a more prominent trend going forward.
Registered nurses have the unique ability to basically choose the type of workplace which best suites his or her ideal environment, usually this happens through trial and error and years of experience.
The RN can work in an environment with pretty curtains and a nice waiting room to a rough-and- tumble county hospital whose primary patient populations are inmates and homeless people. He or she may prefer clean and fresh patients who come from home and have a minor elective procedure or a not-so-fresh patient who was found unconscious in the street and is now barely hanging on for dear life.
- Emergency Room arguably the most fast-paced and dynamic department a RN could choose to work, a day in the ER is never the same twice. Patient populations can be very different depending on the location and size of the hospital
- Intensive Care Unit this department requires perfection, attention to detail, and a strong sense of self to tolerate some of the emotional highs and lows the RN will experience. Large hospitals will have more than one type of ICU:
- Neurological ICU for patients with a traumatic brain injury of some variation
- Cardiac ICU for patients who have had cardiac surgery or cardiac catheterization procedure, or post-myocardial infarction, etc
- Medical ICU for patients with sepsis, withdrawal from a substance, stroke, MI, active gastrointestinal bleeding, etc
- Trauma ICU for patients who have sustained injuries due to a motor vehicle crash, fall, attempted homicide, attempted suicide, drowning, etc
- Burn ICU for patients with a large surface area of burn injury, the RN manages wounds, treats sepsis, and maintains the patient's airway, among other responsibilities
- Pediatric ICU for children or adolescents with life-threatening injuries or diseases, the RN sees miraculous recoveries as well as heartbreaking loss of children
- Neonatal ICU for infants with life-threatening injuries or diseases, like the Pediatric ICU, the RN will experience dramatic highs and lows and requires a strong emotional core to prevent burnout
- Floor patients are admitted to the floor for monitoring and treatment of a stable diagnosis which could deterioration to unstable and require transfer to a higher level of care, such as the intensive care unit. RNs on the floor must be amazing at assessment and rapidly respond to an emergent situation. Floor patient care can be difficult due to high ratios, short staffing including having enough certified nursing assistants, and the fact that, many floor patients are not on telemetry monitoring
- Medical-Surgical is for patients who have had surgery and are stable or have a stable medical diagnosis which may get worse, this unit has a good mix of patients and is often preferred by new RN graduates for it's broad array of experiences
- Orthopaedics is for patients who have sustained a bone fracture and/or need surgery to repair or replace a bone or joint. Common diagnoses for this population is Total Knee or Hip Arthroplasty. The RN helps to rehabilitate and teach this patient about new mobility standards, etc, which must happen for the patient to transfer to home
- Oncology is for patients who have some form of cancer, many are receiving chemotherapy and/or radiation or preparing for a bone marrow transplant, which can require a very long hospital admission. RNs on this unit will experience many emotional highs and lows, so it requires a RN with a strong emotional core.
- Telemetry is for patients with a new or previous diagnosis of a cardiac dysrhythmia, cardiac complication, or have undergone a cardiac surgery. Some telemetry patients are being treated for a different condition but require monitoring of their heart because of a preexisting condition. A telemetry technician is assigned to monitor the EKG's and notify the RN of an abnormality. RNs on this unit must be quick-thinking and understand appropriate cardiac interventions.
- Mother/Baby requires the RN to take care of newborns and post-delivery mothers. This unit is fast-paced and requires quick-thinking and strong assessment skills to monitor for hemorrhage and deterioration of either mom or baby. This nursing role requires the RN to care for 2 patients as a set.
- Psychiatric Unit patients are admitted for mental illness and disease, either temporary or permanent. RNs will be able to explore a wide range of skills relating to mental behavioral health.
- Operating Room RNs will care for patients who require surgery, there are 3 areas of the operating room available to RNs
- Pre-OP, or before surgery, involves the RN obtaining a medical and social history, documenting personal belongings, and preparing the patient for surgery
- Peri-OP, or during surgery, involves the RN assisting or circulating the operating room while the patient is under anesthesia
- Post-Op, or after surgery/recovery room, involves the RN recovering the patient from anesthesia and ensuring the patient's airway and hemodynamics are monitored appropriately while intervening as necessary
- Labor and Delivery RNs assist in delivering babies and everything that comes before and goes after this process. RNs in this area will be working in a fast-paced environment with very high stakes as the birthing process can rapidly escalate to an emergency or surgery. Especially good assessment skills and recognition to a developing crisis is required.
- Cardiac Catheterization Laboratory RNs assist the cardiac surgeon with cardiac catheterization procedures, including cardiac stent placement, intra-aortic balloon pump (IABP) placement, etc. Patients during the procedure are under anesthesia and require intensive monitoring. This patient population has often just experienced a myocardial infarction and was transferred emergently to repair the blocked vessel.
- Radiology RNs perform CT and MRI scans, and X-rays. RN's often inject angiography dye or administer barium for specialized exams.
- Interventional Radiology (IR) the RN in this department assists the physician with procedures such as central line placement, nasojejeunal tube placement, PEG tube placement into the stomach, colostomy insertion, etc. The RN is required to set-up the IR room similar to how an operating room is prepared.
- Wound Care Department the Wound Care RN is specially trained in caring for wounds of various types, colors, and causes. Bedside nurses consult this RN for complex wound care and recommendations as well as Wound Vac initiation and management. RNs in this department should enjoy wound care and are rewarded by the improvement of wounds it's contribution to overall patient health.
- Rapid Response Team is comprised of specialized RNs who are experienced and competent in rapid patient assessment and intervention for the deteriorating patient. A Rapid Response, or RRT, is called on the overhead loudspeaker at hospitals by non-critical care nurses who have determined a patient is deteriorating and needs immediate assistance. This is done when the patient is still breathing and has a heartbeat, so it is not a Code Blue. RRTs will sometimes become a Code Blue if the patient continues to deteriorate and the RRT team needs additional assistance.
Nursing Education Department
For experienced RNs who are gifted at teaching others and strive to develop new policies and procedures for hospitals to ensure excellent patient care is provided by everyone. The Nurse Educator often teaches new graduate RNs during the internship program upon hire.
Skilled Nursing Facilities
Skilled Nursing Facilities are popular for new graduates to, "get their feet wet." In these facilities, new RNs can become excellent at an efficient and timely medication "pass," wound assessment and care, mobility transfers, plan of care, end-of-life, patients who require special memory care who have dementia or Alzheimer's disease, care of family members, and get the basics of how the healthcare system functions from a nursing perspective. Many patients in skilled nursing facilities have deteriorating diseases and require comfort until end of life.
Rehabilitation Facilities are sometimes housed within Skilled Nursing Facilities however the acuity of the this population is higher and requires more RN attention. A patient is usually admitted from the hospital to rehabilitate prior to returning home. They may have experienced a total knee replacement, myocardial infarction (MI, or heart attack), cerebrovascular accident (CVA, or stroke), deconditioned from severe sepsis, or any disease process which caused weakness and an inability to perform activities of daily living (ADLs).
Psychiatric Facilities admit patients with a primary diagnosis of some sort of mental illness or disease and who are unable to perform activities of daily living. They may be admitted temporarily as a bridge to discharging back home while psychiatric medications are adjusted or for suicide prevention monitoring or permanently to monitor for safety. Patients may also be prisoners who are declared mentally incompetent and unsuitable for prison. RNs in this area enjoy a dynamic and complex patient population.
State Prisons often boast high pay and great benefits while promising safety for nurses from inmates. Guards are present for all inmate/patient interactions and RNs must be quick-thinking and possess excellent assessment skills to determine if the patient requires hospitalization.
Outpatient clinics, such as urgent care, ensure the RN will experience a wide variety of illness and disease and must be keenly aware of patients requiring a higher level of care. Patients presenting to clinics often require hospitalization once vital signs are checked or if the condition deteriorates rapidly.
Physician Offices usually offer a "normal" schedule of 9-5 and 5-days a week without requiring nights or weekends. The RN in this setting enjoys patients who are well enough to bring themselves to a physician office and may simply require vaccinations or adjustment of medications. Depending on the type of practice, the RN may assist the physician with procedures or observe exams, as well as collect vital signs, the patient's medical/social history, and anything else required within the Scope of Practice.
Aesthetic clinics include the RN becoming trained, certified, and proficient in procedures such as Botox injections, laser hair removal, body sculpting, tattoo laser removal treatments, etc. The RN in this setting appreciates "well" patients who desire cosmetic procedures. Like a physician's office, the hours in this setting are "normal" as opposed to the hospital setting of 12-hour shifts, including some weekends and possibly requires night shifts.
Telephone Triage, otherwise known as the "nurses line," is usually a service of insurance companies to determine if a patient needs to see a physician or be hospitalized. The patient calls the Telephone Triage RN and states his or her condition, symptoms, etc, and the RN determines, based on protocols, what the patient should do. This position can be very challenging and interesting and the RN appreciates the dynamic nature of the setting. Gaining experience in nursing prior to working in this role may be best.
Learn more about how a telephone triage nurse advises patients and the difficulty of assessing patients for telephone triage nurses.
Organ Procurement Coordinator
Organ Procurement Coordinator is often a RN who is specially trained in bridging the transplant of donor organs to recipients. While this position is not specific to RNs many Organ Procurement Organizations hire critical care RNs because part of the job requirements are to manage a brain dead patient who is always admitted to the ICU and intubated. The RN must take a leadership role and guide hospitals along the donation process then facilitate organ transplant with transplant centers. They speak with families to obtain or not obtain consent and often experience many surprises along the way.
Travel Nurses work in almost any area previously mentioned but are outside of their home state. The Travel RN works with a travel nurse company and accepts 13-week contracts in facilities across the county. This RN enjoys experiencing new places and people and loves change and learning new things. This position often boasts a higher salary due to tax breaks and urgency of hospitals.
While RNs can work in various settings the bottom line is to care for people who need help and cause no harm in doing so. RN school will teach the nurse how to be safe using a standard set of skills and practice under the state's Scope of Practice. The RN is responsible for ensuring an employer is not requiring a task that is outside of his or her scope.
A general rule of thumb is that if the RN is uncomfortable with something he or she should stop and ask someone or check the Scope of Practice and policies and procedures before moving forward. Being scared of hurting someone, for both new graduates and experienced nurses, is healthy and will prevent the RN from doing something which could cause harm. Ever considered the expenses of being a travel nurse?
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RELATED: RN License Transfer and eNLC Guide
Most, if not all, new graduate RNs will accept positions at facilities which require additional training. If the position is highly specialized, such as the intensive care unit, emergency room, or labor and delivery, the training will be longer and more intense than a position in a skilled nursing facility or urgent care.
The skilled nursing facility, urgent care, rehabilitation, and physician's office positions will require a facility orientation and training. The majority of skills required to work in these settings were taught in nursing school but training and orientation allows the RN to learn how to document and perform tasks in the manner required by the facility. Required skills, such as administering vaccinations to infants, may not have been practiced in nursing school and will need to be perfected.
Specialized hospital positions require a facility orientation and training as well as an intense internship with preceptorship before the RN will be able to work without immediate direct supervision.
Internship programs usually consist of a didactic, or classroom/textbook, portion then the hands-on portion. This is the same model as nursing school. These programs are usually overseen and managed by nurse educators and the new graduate RN will not be allowed to take patient assignments alone without being approved by the educator, among others. This program is usually about 6 months in length.
RN licensure information can be found on Nursys.com as well as your actual paper license issued by the state. Be sure to keep track of when it expires and renew before it does. If a RN allows the license to expire he or she will be suspended from work until it is renewed, usually for an additional fee.
Some states require continuing education units (CEUs) for renewal. These are offered at most facilities for required or optional classes and for required certifications, such as Advanced Cardiac Life Support or Basic Life Support both primary and renewal classes. CEUs can also be found online for free and requiring payment. The RN is responsible for knowing CEU renewal requirements for the state in which he or she is licensed. If the RN is ever audited by the State Board he or she will need to show evidence of CEU completion.
No matter which specialty is chosen a career in nursing is a dynamic and lucrative choice. It's the type of career where experience can transfer to many areas of nursing allowing for change. Individuals attracted to careers in nursing tend to be highly intelligent, compassionate, and dedicated. For those who like change and a career with high stakes it may be a great fit.