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Defining a Profession

The nursing profession is a highly specialized field in which knowledge and care are constantly evolving. Nursing has been described as both an art and a science. Nurses utilize knowledge and skills that are based on scientific facts, while performing the art of caring with compassion, dignity, and intuition. Nurses work independently as well as interprofessionally; they can act in the role of a preceptor or supervisor, or be involved in research. But most of all, the nurse provides care to the client and works in collaboration with the health care team to address the client’s needs.

Often society is unaware of or unable to describe what nurses do, or what the profession of nursing involves, because of the broad role the nurse performs. The American Nurses Association has defined nursing in Nursing: Scope and Standards of Practice, a document that provides a framework for all nurses and clarifies what nursing involves and the responsibilities of the nurse as a professional. The scope of practice describes the following.

• What the nurse does

• What the nurse’s responsibilities are

• Where and when client care is to be performed

• Why and how client care is achieved

Model of Professional Nursing Practice Regulation

Nursing is defined by the ANA as follows.

1. Protecting, promoting, and advancing clients’ health

2. Averting illness and injuries through health promotion

3. Using the nursing process to facilitate clients’ recovery from illness or injury

4. Minimizing or eliminating clients’ suffering

5. Advocating for the care and health of the client, family, or community

Nursing: Scope and Standards of Practice forms a solid foundation for a nurse’s practice. However, this document is just one of several resources defining nursing practice.

• A Nurse Practice Act is a legal and regulatory body that is created by, and applicable in, each individual state. It establishes common definitions, rules, and regulations to guide the practice of a licensed nurse and thereby promote quality of care and safety when caring for a client.

• The ANA’s Scope of Nursing Practice provides the nurse with a clear definition of the complex and dynamic role of the nurse and the expectations of the nurse in that role. The ANA’s Standards of Nursing Practice are explanatory statements that describe a competent level of care and professionalism that all nurses should achieve.

• Code of Ethics for Nurses assists a nurse with ethical decision making, by incorporating the nurse’s value system, duty, obligation to the client, and call to uphold professional ideals.

• A nurse is obligated to practice not only within state rules and regulations, but also by following specific policies and procedures within the direction of the facility where the nurse is working.

• A nurse through acquired knowledge, skills, and critical thinking determines the appropriate nursing response based on the scope and standard of practice, rules, laws, regulations, and facility policies and procedures. Based on this self-determination and nursing identity, each individual nurse is responsible for his or her own practice—for making these decisions and acting professionally within the role as a nurse.

• Interwoven throughout all levels of these regulations, laws, standards, and facility policies and procedures are principles of quality, evidence-based practice, and safety, which are critical elements of every decision and action a nurse takes in practice.

Historical Contributions

For more than 200 years, nurses have been at the forefront and on the front lines of providing care to those who are sick and injured as well as preventing illness, traumatic injuries, and the spread of communicable diseases. Nursing had its early beginnings with volunteers (of all genders) who had little formal education but nevertheless cared for injured and sick soldiers. However, in Florence Nightingale’s era, society’s impression of the role of nursing changed, such that nursing became viewed as primarily a female role. It was assumed that because females were the nurturers and caretakers of their children and family members, they would be better at providing the caring and nurturing that nursing required. In turn, men became reluctant to serve as nurses and found jobs in other professions. Even as recently as the 1980s, studies showed that society often perceived men who entered the nursing profession as deviants or failures—that they entered nursing because they weren’t intelligent enough to become physicians. These men were often thought of as less educated or unsuccessful at securing other jobs, which made the nursing profession less desirable for men. Currently, nursing continues to be predominately female, with men representing only approximately 11% of all students pursuing their BSN degrees, a percentage that has remained steady over recent years.

In the late 19th century, society recognized the need for nurses to have formal education in the nursing discipline. In 1872, the first school of nursing opened. This development had a ripple effect across the United States, as many hospitals built their own schools of nursing. For the most part, these schools of nursing provided hands-on clinical experience and very little theoretical classroom learning. As health care evolved and technology exploded, by the 1970s many colleges and universities began to offer two- and four-year nursing degrees. These programs entailed a combination of clinical and classroom learning.

In the early 1900s, nurses were not licensed and did not have any professional organization to provide them with a strong collective voice to represent the nursing profession or advocate for the health care needs of their clients. Today, in contrast, male and female nurses are highly respected, well-educated leaders in health care.

As nursing moves further into the 21st century, the profession has evolved in several respects since its early beginnings—in nursing education, licensure, creation of advanced practice roles (nurse practitioners), certification, and professional organizations. However, one thing remains constant: The focus throughout nursing history (and currently) has been to reduce harm and the negative impact of crises on nurses and their clients, as well as to promote healing and health resulting in maximum success for the clients.

In 2020, the Smithsonian Institute celebrated the 200th anniversary of the birthday of Florence Nightingale, one of the most prominent figures in nursing history. Nightingale demonstrated what is now called evidence-based practice, by engaging in data collection and reporting her findings. She connected unclean conditions to wound infections during the Crimean War (1854–1856) and observed that overall cleanliness, hygiene, and antisepsis when caring for soldiers reduced infection rates​​​​​​​. Nightingale continued her legacy by starting some of the first schools of nursing. During the Crimean War, she was called “the lady with the lamp” because she carried a lamp at night to check on the soldiers. Nightingale not only illuminated the darkness of the path she walked, but also the path nurses have taken ever since, who continue to advance her vision for change.

Other pioneering nursing leaders included Clara Barton and Dorothea Dix. Barton personally served in the battlefields, bringing necessary supplies, comfort, and food to the wounded. She created a center to locate missing soldiers and started the American Red Cross. Dix was not a nurse, but rather a teacher. She volunteered to care for soldiers during the Civil War, and was subsequently appointed Superintendent of Army Nurses for the Union Army. In this role, she set up temporary hospitals on the battlefield, organizing and training nursing recruits. Like Nightingale, Dix pushed for formal training for nurses. She was best known for her advocacy for mental health reform and indigenous rights. These courageous women, like so many during that time, risked their lives to care for soldiers and formed the strong foundation for many of the principles of nursing today.

Twentieth-century nursing leaders also offer examples for inspiration. Ildaura Murillo-Rohde earned her doctorate in nursing in the 1970s and founded the National Association of Hispanic Nurses (NAHA). Eddie Bernice Johnson faced segregation as a student, and was the first registered nurse elected to the U.S. Congress, as a representative from Texas. In 2012, she introduced the STEM (science, technology, engineering, and mathematics) Education Act in the U.S. House of Representatives, which would provide grant awards to minority students.

Nursing Education

Nursing is a unique profession, with its varying levels of education for nurses, depending upon the length of time of the program and the degree desired. The choice of nursing program to pursue is often made according to the final degree desired. The many options for obtaining a nursing degree are divided according to the levels of advancement within the profession.

• Prelicensure nursing education programs

  • LPN: A licensed practical nurse (LPN) or licensed vocational nurse (LVN) degree can be obtained in one year.

  • RN: A registered nurse (RN) degree can be achieved in two to four years, depending on which of the following educational programs is chosen:

    • Diploma nurse: Hospital-based, non-degree

    • ADN: Associate degree in nursing

    • BSN: Bachelor’s degree in nursing

• Graduate nursing educational programs: Nurses in these programs have either a master of science in nursing (MSN) or a doctorate level of education, along with advanced abilities, experience, knowledge, and critical-thinking skills that enable them to practice without additional regulations.

  • Certifications: A variety of skill-based and educational-based national certification recognitions are available to show knowledge and expertise in specialty and advanced practice areas, such as advanced practice registered nurses (APRNs).

  • MSN: Master of science in nursing

  • Doctoral

    • DNP: Doctor of nursing practice—a clinical practice degree

    • PhD: Doctor of philosophy in nursing—a research-based degree

• Lifelong learning

  • Patricia Benner (1982) has described the transition from novice to expert.

  • Continuing education: Lifelong learning helps to improve or maintain competency and ensure the best client outcomes.

advanced practice registered nurses (APRN)

LPNs and LVNs practice nursing under the supervision of an RN. Historically, ADN programs were designed to meet the demands for care under a nursing shortage, by allowing candidates to earn an RN degree in only two years. Today, these programs continue to fulfill staffing needs, as well as being a cost-effective way to earn an entry-level position as an RN. These RNs are then encouraged to complete their BSN, so as to more fully satisfy the goals of the profession. Nurses who have earned a BSN or beyond have a wider range of competencies related to professionalism, research, leadership, community health care, developing health policy, and quality improvement processes​​​​​​​.​​​​​​​

Each nursing degree has different lengths of study and difficulty, but all candidates for degrees are required to take the same National Council Licensure Examination (NCLEX) after graduating from their prelicensure program. Nursing programs are structured to provide students with the information and experience to succeed. Students are required to pass the NCLEX licensure exam to receive a license to practice. Upon passing the licensure exam, nurses are expected to follow the Nurse Practice Act for the state in which they practice.

Nurses who choose to further their education, or work in advanced practice, or pursue higher education, have many options available to them to achieve these goals. Nurses must first earn a BSN degree, and then may be required to earn an MSN, along with other certifications and experience. The options depend on the level of degree or experience obtained and the area of expertise desired. As the complexity of care increases, nurses are asked to think beyond the BSN degree, which should now be considered the preferred entry into the profession​​​​​​​.

One advanced degree option is the DNP degree. This degree was recommended by the American Association of Colleges of Nursing to become the next step for APRNs—among them, nurse practitioners, nurse anesthetists, and clinical nurse specialists. It was designed to be the terminal degree in nursing practice, instead of the MSN. The DNP prepares the advanced practice nurse for leadership roles and clinical practice when caring for clients with complex needs. DNPs focus on applying research and knowledge to improve clinical practice and obtain positive client outcomes for specific populations.

Another advanced degree option in nursing is the PhD degree. This degree is research- and science-focused, with emphasis on evidence-based analysis of statistics and research. Nurses who hold a PhD generate research that supports nursing actions, and contribute to the scientific and factual relevance and professionalism of nursing.

Digital Learning and Technology in Nursing Education

Technology trends in education include online learning, use of electronic devices, and simulation experiences. Online learning resources have the advantage and flexibility of availability and ease of use for the learner, allowing the student to continue to work and care for family while not being in a classroom. These resources are designed to be individualized and provide feedback and support. Online study is eco-friendly, cost-effective, and continually updated. This type of learning may also present some challenges, such as depersonalization, technical difficulties, and decreased student/teacher interaction​​​​​​​.

Courses and books are still part of the classroom curriculum, and are often designed to be viewed on personal devices, which allow further flexibility in availability of learning resources. Classrooms are still predominately held on campus, as face-to-face learning has its place and many courses cannot be completely taught online. Online learning requires excellent time management as well as effective technical skills to achieve the desired outcomes. It works well for building a knowledge base. Procedures that require coordination and skills of dexterity, as is the case for many nursing procedures, may require high fidelity simulators to gain proficiency with these techniques​​​​​​​.

Simulation is an experience that often uses a computerized manikin to model or replicate a clinical experience, allowing for a safe and reflective learning environment. Simulation uses a range of approaches for practicing skills, depending on the level of student and the experience desired, ranging from an entry-level communication experience to a senior-level student group in an advanced skills scenario. Simulation offers opportunities to practice skills and learn in simulated real-life experiences, within a safe and controlled learning environment. Students are not expected to know everything at once, but may prepare for the experience and then learn through repetition and by communicating and collaborating with their peers. Valuable feedback is given during the review or debriefing of the simulated scenario in real time to enhance student learning.

Transitioning From Novice to Expert Nurse

Lifelong learning occurs throughout the nursing career, whether that learning happens through individual study or by working with others. Nurses gain valuable experience by interacting and learning from other nurses, and by sharing knowledge, best practices, and expertise. Respect for the knowledge of others, regardless of years of service, is the key to valuing all levels of proficiency, as length of experience is not the only determination of knowledge. Nurses in leadership positions can be valuable in establishing a collaborative culture and encouraging positive interactions between new and experienced nurses, while creating an atmosphere of mutual respect and a solid foundation for teamwork.

Dr. Patricia Benner introduced the novice-to-expert model for nursing competence in 1982, detailing how nurses develop skills and understanding of patient care. This model remains relevant today, as it describes how a nurse progresses through five stages as new skills and knowledge are acquired, ending at the expert stage. Nurses can gain valuable knowledge by collaborating with and observing nurses with more experience and expertise in the field or specialty. The five stages of proficiency in the novice-to-expert model are novice, advanced beginner, competent, proficient, and expert.

Stage 1: Novice

This initial stage covers nursing students and new nurses who have no previous experience. Novices cannot yet draw on their own judgment. The novice struggles to decide which tasks are most relevant in real-life situations.

Stage 2: Advanced Beginner

The advanced beginner has been involved in enough real-world situations to be able to recognize patterns and recurrent situations. A problem at this stage is that the focus is on remembering and following the rules and guidelines that have been taught. The advanced beginner needs clinical support to set priorities so that clients receive the care they need.

Stage 3: Competent

The competent nurse is able to prioritize tasks by drawing on past experiences. These nurses may not function with the same speed or ease of change as proficient nurses, but they have mastery in multiple areas. Competent nurses recognize patterns in clinical situations more quickly and accurately than advanced beginners can.

Stage 4: Proficient

The proficient nurse is able to understand the bigger picture or the desired outcome of situations, which facilitates improved decision making. Proficient nurses are able to respond to changing situations and modify plans in the face of different events.

Stage 5: Expert

The expert nurse has extensive experience and knowledge to draw from when responding to complex client conditions. At this stage, nurses have self-confidence and trust their intuitive sense of a situation. Expert nurses know what needs to be done and are able to perform it well