The Second Career Nurse: A nurse is a nurse is a nurse…? Not exactly

Many people are confused by the many different kinds of nurses, and there are a lot. You may not understand the difference between say a nurse with an associate’s degree from a community college, and a nurse with a bachelor’s degree, or how they compare to a nurse practitioner. To allay any confusion, I thought this would be an excellent time to lay out the various types of nurses and explain the differences between them in terms of education and role.

Certified Nurse Assistant (CNA)

Certified nurse assistants may be known variously as CNAs, nurse’s aids, patient care technicians, home health aids, or home health assistants (HHAs). CNAs are entry-level health professionals responsible for assisting patients with their activities of daily living, such as bathing, eating, and using the bathroom. The education requirement is usually a certificate program from a community college, often taking only a few months. A CNA works under the supervision of a registered nurse in a hospital, nursing home, adult living facility, or private home. Their intimate physical contact with the patient makes them a valuable resource for registered nurses to learn more about the condition of their patient.

Licensed Practical Nurse (LPN) / Licensed Vocational Nurse (LVN)

You can think of LPNs or LVNs (which are the same, just different names given to them in different states) as registered nurses light. They provide basic bedside care including taking vital signs, preparing and passing medications, providing wound care, and assessment. LPNs are trained to monitor patients for reactions to drugs, help patients with activities of daily living. The education requirement for these nurses is a certificate program at a community college or technical school and generally takes about a year, at the end of which they take the National Council Licensure Examination – Practical Nurse (NCLEX-PN). LPNs are somewhat limited in their practice, working under the supervision of a physician or registered nurse, often requiring supervision while administering medications. For this reason, I highly recommend pursuing at the very least an associate’s degree in nursing, which I will discuss next.

Registered Nurse (RN) with an associate’s degree (ADN)

In the medical community, when someone is referred to as a “nurse”, it is assumed that they are talking about a nurse at this level or above. This is because an associate degree nurse (ADN) or associate of science in nursing (ASN) has taken the National Council Licensure Examination – Registered Nurse (NCLEX-RN). This is the exact same license under which a nurse with a bachelor of science degree (BSN) practices. In fact, it is often the exact same degree that a nurse prepared at the master’s level will practice under. Right now, 50-60% of practicing nurses in the United States are educated at this level. If you were to walk into a typical hospital, you would not be able to tell an associate degree nurse from a bachelor’s or master’s prepared registered nurse because, as mentioned, they are practicing under the same license and are, technically speaking, equally qualified. However, an ADN has a 2 year degree from a community college or online program, while other RNs typically have obtained a 4 year bachelor’s degree or have pursued on of the unique routes to a bachelor’s or master’s degree discussed later. ADNs provide direct patient care at the bedside, carry out physician orders, and initiate independent nursing interventions on their own authority. They can administer medications without supervision and work under their own license.

Registered Nurse (RN) with a bachelor’s degree (BSN)

Registered nurses with a bachelor of science degree in nursing (BSN) make up the core of nursing. These nurses have generally completed a 4 year nursing degree program at a university and have taken and passed the National Council Licensure Examination – Registered Nurse (NCLEX-RN). However, as you will see, there are accelerated BSN programs that train non-nurses who hold bachelor’s degrees in other fields to be BSNs in as little as 12 months. So if a BSN and an ADN are practicing under the exact same license, why would anyone go to school for those extra 2 years? The answer is marketability and opportunity for advancement. A BSN has an advantage over an ADN in the job market with many employers, especially large academic medical centers, preferring to hire BSNs over ADNs. In fact, I know for a fact that more and more hospitals are exclusively hiring nurses with a bachelor’s degree or higher, with the exception of current employees (for instance CNAs who have earned an associate’s degree in nursing); and even these in-house hires are expected to earn a bachelor’s degree within a specified period of time. This is because the percentage of nurses with a bachelor’s degree or higher increases a hospital’s national rankings as well as helping them to obtain “magnet” status, a designation given to hospitals which meet certain requirements including level of nurse education, patient outcomes, and nursing staff job satisfaction. Nursing organizations also have the goal of increasing the percentage of nurses in the work force who hold a bachelor’s degree and to eventually make this the minimum entry-level education requirement to enter the profession. I recommend anyone entering the nursing field to obtain at least this level of education. Why? Because not only will you find it much easier to find a job, having this degree or higher will make it much easier for you to advance to positions such as charge nurse, preceptor, or nurse manager, should you desire that in the future. It also serves as a great foundation for obtaining the higher nursing degrees that will be discussed next.

Registered Nurse (RN) with a master’s degree (MSN)

This is where nursing education and roles really get confusing. This is because there is a distinction between a nurses’ education level (i.e. master’s degree), the license they practice under (i.e. Registered Nurse, Clinical Nurse Specialist, Nurse Practitioner), and their role (i.e. their day to day responsibilities). This will be much clearer to you by the time you are finished reading this guide, I promise. To help make it clearer I have divided this section according license type and will then discuss the role of the nurse practicing under each type of license. Keep in mind that all of the nurses I will discuss in this section are educated at a master’s level and have a master of science in nursing (MSN) degree. Ok here we go!

Registered Nurse (RN) / Clinical Nurse Leader (CNL)

Clinical nurse leader (CNL) is a relatively new nursing role. It was developed by the American Association of Colleges of Nursing (AACN) in 2005 with the goals of improving patient care and training nurses competent in the translation of research evidence into clinical practice. Clinical nurse leaders are educated at the master’s level and are considered advanced nurse generalists, meaning that they are not specialized in a particular area of nursing. This distinguishes them from other master’s prepared nurses that are considered advanced practice nurses (APNs) due to their specialization in a particular clinical area and expended scopes of practice. CNLs practice under their RN license, the same license under which associate degree nurses and bachelor’s degree nurses practice. So what is the difference between a CNL and these other nurses? First of all, CNLs are educated extensively on evidence based practice and quality improvement as well as given a strong background in research. This makes them better prepared to deal with a changing healthcare environment by training them to think outside the box and be constantly looking for ways to improve the unit on which they work, be it improvements in clinical safety or cost effectiveness strategies. These skills are verified through an examination at the end of every CNL program which grants the nurse a clinical nurse leader certificate. These skills make the CNL very attractive to potential employers and the fact that they hold a master’s degree makes them much more “promotable” within the organization. I highly recommend this route to anyone who holds a bachelor’s degree in another field and wants to become a nurse. Programs that offer the CNL degree will be discussed later in this guide.

Clinical Nurse Specialist (CNS)

A clinical nurse specialist, as the name implies, is a clinical expert in a specific area of nursing practice. Aside from having a master’s degree in nursing (MSN), they are also certified as clinical nurse specialists through their state’s board of registered nurses. CNS’s, along with nurse practitioners, nurse midwives, and nurse anesthetists, are considered advanced practice nurses (APNs). What distinguishes an APN from other registered nurses? APNs are legally granted an expanded scope of practice, meaning they can perform procedures, order tests, prescribe medications, or other actions that other registered nurses are not legally allowed to do. Don’t worry, it will become a lot clearer as you move through this guide. The clinical nurse specialist is often in charge of training and education of registered nurses practicing in their clinical area within a hospital. So what specialties can a clinical nurse specialist go into? Here is a list of the most common CNS specialties:

Acute Care

Adult

Family

Gerontology

Pediatrics

Women's Health

Psychiatric/Mental Health/Adult

Psychiatric/Mental Health/Child

HIV/AIDS

Nurse Practitioner (NP)

Nurse practitioners have a drastically different role in healthcare delivery than the types of nurses discussed so far. The primary role of the NP is not providing bedside care and safely implementing physician orders. Instead, the NP acts a lot closer to the role of the physician, ordering and interpreting tests, diagnosing disease, and prescribing medications. Keep in mind, depending on the state in which the NP works, they may have more or less independence in their practice. For instance, some states require NPs to be directly supervised by a physician while other states allow nurse practitioners to open independent practices and directly bill Medicare and insurance companies. In addition to the master’s degree, NPs hold a nurse practitioner certificate. This is earned after completing an approved nurse practitioner program and then taking a board certification exam. It is important to note that nurse practitioners are also registered nurses and can perform all of the bedside care performed by any RN. Nurse practitioners, like CNSs, choose a specialty. These include: