RN. There are 3 courses of study that can lead up to becoming an RN. The first is a diploma in nursing. This is a 3 year hospital based course. This is the way all RN's were originally trained, however there are very few diploma programs still in existance. The second path to becoming an RN is an associate degree in nursing. This is a 2 year course taught at a community college or junior college. More RN's have this degree than any other. The 3rd way to become an RN is a Bachelor of Science in Nursing (BSN). This is a 4 year university degree. Individual courses in physical assessment, nursing research, and community health nursing are part of a BSN program, while I don't think these are included in an associate program. Regardless of course of study, all RN candidates take the same exam. Some nursing positions and hospitals require a BSN. At Scott & White Hospital, BSN's were paid $0.18 more per hour than ADN's, but I don't think there is a pay difference at most hospitals.
LPN or LVN (Licensed Practical or Vocational Nurse). This is a 12 month program. Scope of practice for LVN's varies from state to state and hospital to hospital. In the Texas Nurse Practice Act, there is nothing specifically prohibiting LVN's from performing certain skills; that is left up to the individual hospital. At St. Joseph Medical Center, LVN's could not perform the admission assessment, start a blood transfusion (though they could monitor it once it was started by an RN), or give IV push medications. The same rules applied at Scott & White Hospital, but LVN's were not able to do discharge teaching either. At Washington Hospital Center in Washington, DC, the LPN's performed exactly the same functions as the RN's. Some hospitals do not hire LPN's. LPN's commonly work in clinics and doctors' offices.
CNA (Certified Nursing Assistant). I think this is a 6 week course, though I could be wrong about that. CNA's take all the vital signs (obs), check blood sugars, collect lab specimens, take weights, record intake & output (fluid balance), bathe & clean patients, make beds, feed patients, bring water & snacks, empty bedpans, urinals, & urinary catheters, etc. At the 2 hospitals I worked that did not have phlebotamy teams, the CNA's also drew all the peripheral blood tests.
Competancies. As a new grad, there are certain competancies on which nurses must be checked off. This is fairly informal. The new grad would be checked off by their preceptor. Hospitals do not have policies and procedures for performing basic clinical skills. As an experienced RN, it would be expected that you would know how to perform clinical skills appropriately. There are no competancy check offs for experienced RN's. Chemotherapy certification and Advanced Cardiovascular Life Support are national certifications and are recognized by all hospitals.
Medication checks. Chemotherapy, heparin drips, TPN, and PPN (total and peripheral parenteral nutriton) must be double checked and signed off with another nurse. At some facilities insulin and subcutaneous heparin must be double checked and signed off with another nurse. For narcotics and some sedatives, a second nurse is required to check and sign only if a partial dose is to be given (i.e., 1mg of a 2mg vial is to be given). If the full dose is to be given, a 2nd nurse is not required. Those are the only medications that are required to be double checked with another nurse, at least in the nursing specialties in which I've worked.
Documentation. This varies from hospital to hospital. There is the intake & output (fluid balance chart), physical assessment, nurse's note, care plan, acuity chart, and admission assessment. I probably spend at least 2 hours of each shift in documentation.
Physical assessment. It is the responsibility of the nurse to perform a head to toe physical assessment of the patient every shift. This usually involves the neuro, respiratory, cardiovascular, gastrointestinal, urinary, & integumentary (skin) systems. The nurse is expected to listen to lung, heart, & bowel sounds with a stethoscope. If there is any question of neuro deficiency, the nurse is expected to check the patient's pupils for size & reactivity, test strength in all extremities, & determine level of consciousness.
Technology. Most medications are kept in a medication machine called Pyxis, Accudose, or Omnicell. The machine is operated by a touch screen computer. The nurse enters the patient's name then chooses from the list of that patient's medications. A drawer containing the medication opens. Most hospitals are at least partially if not completely computerized when it comes to documentation. Vital signs (obs), nursing assessments, intake & output (fluid balance), medication administration, progress notes, doctors' orders, etc. are computerized. All patient armbands and blood labels are printed from a computer.
Supplies. Plastic aprons and safety goggles are not required to be worn for any procedures or skills. The only exception to that might be goggles when dealing with chemotherapy. Isolation gowns are worn when a patient is on contact precautions for MRSA, VRE, c.diff, or pseudomonas. There is both primary & secondary (piggyback) IV tubing. A primary IV fluid will be attached to the primary IV tubing. All other medications (chemo, antibiotics, potassium, antiemetics, etc.) are attached to the piggyback tubing, which is connected to a port (bung) in the primary IV tubing above the point where the primary tubing is in the pump. Both primary & piggyback rates and volumes can be set on the IV pump. Once the piggyback medication is complete, the IV pump automatically switches to run the primary IV fluid. There are no IV flushes to be given and no disconnecting done unless multiple secondary medications are to be given. IV tubing may be disconnected then reconnected to a patient so long as a sterile cap is placed on the end of the IV tubing. Patients are disconnected from IV lines to shower, unless the IV fluid running is something that cannot be interrupted such as chemo, a blood transfusion, or TPN. To access an IV port (bung), it must be swabbed with 1 alcohol wipe. Emesis (kidney) basins are not used for holding supplies. Medications that need to be drawn up are done so on the counter (bench) in the medication room. General waste is not double bagged. Chemo waste might be different. Urinals and bedpans are not reused for multiple patients but are thrown away once the patient is discharged.
Sterile procedures. A central line dressing change is a sterile procedure. All needed supplies come in a prepackaged pack. The entire process takes about 5-10 minutes to do. Accessing port-a-caths and removing PICC lines are not sterile procedures. The handwash prior to doing a central line dressing change is no different than a regular handwash.
Vacation time. The usual amount of PTO (paid time off) is 4 weeks/year. PTO is based on number of hours worked, so the more hours you work, the more PTO you get. There are no monthly rostered days off, and no extra PTO is awarded for shift work or working Sundays.
Sick time. Employees accrue sick time, but at St. Joseph Medical Center, you could not use your sick time until you had already used 3 days of PTO. You also had to have a note from a doctor in order to collect on your sick time. Any sick time remaining when you left the facility was lost. This might be different at other hospitals.
Shifts. Most of the hospitals I have worked at operated on 8 and 12 hour shifts. One hospital offered only 12 hour shifts. Some hospitals have certain floors (wards) that operate on 12 hour shifts only or 8 hour shifts only. Most of the floors (wards) I've worked on are a combination of both. 12 hour day shift is 7A-7:30P, 12 hour night shift is 7P-7:30A, 8 hour day shift is 7A-3:30P, 8 hour evening shift is 3-11:30P, & 8 hour night shift is 11p-7:30A. At St. Joseph Medical Center shifts were 6:30A-7P, 6:30P-7A, 6:30A-3P, 2:30P-11P, & 10:30P-7A. Employees are hired to work a specific shift (i.e., nights only).
Uniforms. Nurses do not wear a uniform as such. All clinical (dealing with patients) nurses wear scrubs. Shorts are not allowed to be worn by hospital employees and would be considered very unprofessional. St. Joseph Medical Center and Scott & White Hospital had color coded scrubs, i.e., all nurses wore royal blue scrubs, all nurse aides wore ceil blue scrubs, all secretaries (administrative officers) wore maroon scrubs, etc. At all the other hospitals I worked, nurses could wear whatever color of scrubs they chose. Most nurses wear tennis shoes (sneakers) or a type of clog made specifically for medical personnel. Shoes can be any color. Most of the places I have worked did not have jewelry restrictions. At St. Joseph Medical Center, earrings were supposed to be no longer than chin level. Wristwatches are the norm. I have seen only 2 nurses besides myself with fob watches.
Unions. There were state nurses unions in New York, Illinois, California, and Massachusetts. I'm sure there are other states with unions too. There was not a district union for DC, but Washington Hospital Center had its own union. There is no nurses union in Texas. At some hospitals, nurses are required to be a member of the union. I know in New York and Boston, some hospitals were union and others were not. Unions do not provide indemnity (malpractice) insurance. I think the union dues for the Massachusetts nurses union were $700-$800/year, but I'm not sure of that.
Licensure. State-by-state. There is something called the Nurse Licensure Compact, of which 23 states are a part. A nurse who received their first nursing license in a compact state may legally practice nursing in any other compact state without having to obtain a license there. However, for nurses who received their first license in a non-compact state, if they want to work in compact states, they have to obtain a license in each compact state in which they want to work. I find this defeats the purpose of the compact. Luckily, my first license was in a compact state. Requirements for licensure vary state to state. I think the least expensive license fee I paid was $50 for Illinois, and the most expensive was $250-$300 for DC. The shortest wait time was 2 weeks for Hawaii, and the longest was 8 months for Illinois. Some of the requirements for licensure are fingerprinting, nursing school transcripts, verification from nursing school, and license verification from every other state of licensure. Licenses must be renewed every 3 years in New York and every 2 years in other states. Nurses must obtain a certain number of hours of continuing education for licensure renewal.
Beds and baths. Nurses rarely make beds or give baths, and when they do, it is usually helping the CNA. CNA's make the beds and give the baths.
OB nurses. Obstetrical nursing is a semester long course taught in each nursing school. Nurses can specialize in labor & delivery, postpartum (mother/baby), and antepartum. Midwives are fairly rare and have a very similar role to that of an OB doctor.
Holiday pay. Time & a half for all holidays.
Patient to nurse ratios, pay rates, hours, etc. vary from hospital to hospital even in the U.S. These are the hospitals I've worked at in a nutshell.
Washington Hospital Center, Washington, DC. Traveling nurse pay rate =$33/h + housing. There were no shift diffs or weekend diffs for traveling nurses. I received holiday pay for working Thanksgiving. Full time for traveling nurses was three 12h shifts/week. Full time for regular staff was two 12 & two 8 hour shifts/week. At least half of your shifts had to be evenings or nights. There was a weekend crew who worked two 12 hour shifts every Sat./Sun. & were paid for 36 hours. I had to work about 2 weekend shifts every 3 weeks. Max patient:nurse ratio was 4:1 for the resource (charge) nurse & 6:1 for everyone else. For a 34 bed unit, there were usually no more than 2 CNA's, and quite often only 1 or none. Other than taking vital signs, bathing patients, and making beds, most usual CNA responsibilites fell on the nurse. IV & phlebotamy team.
Mount Sinai Medical Center, New York, NY. Traveling nurse pay rate = $32/h + housing. There were no shift diffs or weekend diffs for traveling nurses. Full time was three 12h shifts each week with a fourth 12h shift every 4th week. I had to work about 1 weekend shift every 3 weeks. Nurses were responsible for checking all blood sugars. There was no IV or phlebotamy team or respiratory therapists. No max patient:nurse ratio. Usually 5 or 6:1 on days and 6 or 7:1 on nights. The most I ever had was 7 on days and 9 very briefly on nights.
University of Chicago Hospitals, Chicago, IL. Traveling nurse pay rate = $26.75/h (2008) & $25/h (2009). Evening, nite, & weekend day diff = $2/h (2008) & $1/h (2009). Evening & nite weekend diff = $4/h (2008) & $2/h (2009). I received holiday pay for working Thanksgiving. Full time = three 12h or five 8h shifts/week. Every other Sat./Sun. mandatory. Phlebotamy team. Max patient:nurse ratio was 5:1.
Mills-Peninsula Hospital, Burlingame, CA. Traveling nurse pay rate = $26/h + housing + $273/week for meals. No weekend diff for traveling nurses. New grad staff nurse pay rate = $44/h. Full time = five 8 hour shifts/week. Every other Sat./Sun. mandatory. Nurses check all blood sugars & do all dressing changes including wound vac dressings. Phlebotamy team. Max patient:nurse ratio was 5:1.
Brigham & Women's Hospital, Boston, MA. Traveling nurse pay rate = $19.25/h + housing + $245/week for meals. No shift diff or weekend diff for traveling nurses. For regular staff, Columbus Day & Veteran's Day received holiday pay. For regular staff, any hours worked after a 12 hour shift were paid double time. Full time = three 12h or five 8h shifts/week. Max patient: nurse ratio from 7A-11P 3:1 & from 11P-7A 4:1. IV team & phlebotamy team.
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