The health care system continues to undergo dramatic changes. Social and economic factors create a state of constant evolution. Professional nurses respond by creating innovative alternatives to traditional nursing practice to meet these new challenges. As nurses proactively define solutions to today's health care dilemmas, multiple career opportunities emerge.

Not long ago most nurses considered acute care hospitals to be the main practice setting available to them after graduation. Few other career choices were available. Public health nursing was one of few exceptions providing variety in the nursing job market. With health care trends moving from inpatient treatment to outpatient and home care and acute care to health promotion and disease prevention, the United States society is seeking alternative settings to meet this growing need. This shift in health care settings creates a variety of choices for nurses exploring career opportunities.

Nurses today have more liberty to explore and even create job opportunities. Nurses may continue to select the hospital or acute care setting or may venture into less traditional nursing roles. It is imperative that nurses claim ownership of nontraditional roles as they emerge in the health care job market. As a profession, nurses should exercise their influence to develop and support new nursing roles. This chapter presents an overview of some key opportunities available for RNs today in the United States. Included are demographics of today's nurses, as well as implications for the future.

This chapter examines the traditional and less traditional options available and the current and future issues for roles in professional practice.


 Not so long ago describing the role of RNs was simple because there were few opportunities for variation. Today exploring job opportunities for RNs is more complicated as nurses are practicing in literally hundreds of diverse settings with a broad variety of clients. The proliferation of career opportunities for nurses is growing. Although nursing roles have expanded, the traditional functions of the nurse remain intact.

24-1 summarizes the roles nurses will assume in any employment role or setting.

Care Provider

The role of care provider is basic to the nursing profession. As the provider of care, the nurse assesses client resources, strengths and weaknesses, coping behaviors, and the environment to optimize the problem-solving and self-care abilities of the client and family. The nurse plans therapeutic interventions in collaboration with the client, physician, and other health care providers. In addition, the nurse takes responsibility for coordination of care that involves other health professionals or resources, providing continuity and helping the client deal effectively with the health care system. As part of the care provider role, caring will always be central to nursing interventions and an essential attribute of the expert nurse.

Educator and Counselor

Multiple factors increase the need for nurses to serve as educators. Today the new emphasis is on health promotion and health maintenance rather than on management of disease conditions. The role of nurse counselor has been elevated to new heights. More than ever before, nurses encourage clients to look at alternatives, recognize their choices, and develop a sense of control in a rapidly changing health care environment.

Client Advocate

Professional nurses find that the role of client advocate is essential in multiple situations with a multitude of client populations. Promoting what is best for the client, ensuring that the client's needs are met, and protecting the client's rights remain important responsibilities of the professional nurse.

Change Agent

When nurses first adopted the role of "change agent," few individuals visualized to what extent nurses would fulfill this role. However, nurses have expanded their role as change agents in many ways. The profession continues to identify client and health care delivery problems, assess their motivation and capacity for change, determine alternatives, explore possible outcomes of the alternatives, and assess cost-effective resources in infinite health-related situations.

Leader and Manager

The leadership role of the professional nurse is paramount to the health care system. Today nursing leadership varies according to the level of application and includes:

• Improving the health status and potential of individuals or families.

• Increasing the effectiveness and level of satisfaction among professional colleagues providing care.

• Managing multiple resources in a health care facility.

• Raising citizens' and legislators' attitudes toward and expectations of the nursing profession and the health care system.

There is little doubt that the management role of the nurse has become more important. Nursing management includes planning; giving direction; and monitoring and evaluating nursing care of individuals, groups, families, and communities.


During the past decades nursing has taken its place among other disciplines in the production and use of research specific to its profession. Although the majority of researchers in nursing are prepared at the doctoral and postdoctoral levels, an increasing number of clinicians with master's degrees are beginning to participate in research as part of their advanced practice role. Nurses prepared at the baccalaureate and associate degree levels are also participating in research. These nurses may be assisting with data collection, critiquing research findings, and using these findings in practice. More nursing interventions are based on nursing research than in the past.

Coordinator of the Transdisciplinary Health Care Team

Transdisciplinary teams consist of collaborative practice relationships among several disciplines of health care professionals. The disciplines include nursing, medicine, pharmacy, nutrition, social work, and other allied health professionals such as physical therapists, respiratory therapists, occupational therapists, and speech therapists. Chaplains or pastoral care representatives also serve a very valuable role on the transdisciplinary health care team. These teams are found in all health care delivery settings and function most effectively when their focus revolves around the needs of the client.

Transdisciplinary teams are valuable because professional members bring their in-depth and specialized knowledge and skills to the interaction process. In an age of exploding information, the roles of transdisciplinary team members complement one another. Through the formal and informal communication of ideas and opinions of team members, health care plans are determined. A plan of care developed by the transdisciplinary team is usually considered a valuable health management tool (Van Ess Coeling and Cukr, 1998).

The term transdisciplinary health care team may not be as familiar as the term multidisciplinary or interdisciplinary team. Multidisciplinary health care teams consist of many disciplines involved in meeting client care needs. Interdisciplinary teams refer to coordination between and among disciplines involved in providing client care. The more global and inclusive term transdisciplinary health care teams can be described as including multiple disciplines bonding, interacting, and uniting toward common goals of client care. The collaborative process involved in transdisciplinary health care incorporates the definitions of multidisciplinary and interdisciplinary health care and, in fact, transcends a single health profession to create comprehensive work outcomes. Studies that investigate the process of transdisciplinary health care teams in action report improved quality of care, increased client satisfaction, increased nursing satisfaction, and reduced hospital cost by decreasing hospital length of stay and increasing nursing retention (Wasserman, 1997; Baggs, 1989; Baggs et al., 1992; Knaus et al., 1986).

Successful health care team models that use concepts related to transdisciplinary health care include pain management, nutritional support, skin care, rehabilitation, mental health, and hospice. Discharge planning, which emerged as a major focus of health care delivery in the 1980s and involves developing a plan of treatment that ultimately results in the discharge of the client from the health care facility, is built on the concept of transdisciplinary care, with each discipline involved in providing care for the client included in developing the discharge plan.

Client education is another area in which collaboration and disciplines working together are absolutely essential. Health care professionals must understand one another's contributions to client education and ensure that the information clients and families receive is consistent and complete. This will lead to the best possible health outcomes for clients and families.


The phrase "a typical nurse" has become a misnomer as the profession enters the twenty-first century. Nursing roles are so diverse that there literally is no typical role or practice setting. Recent surveys conducted by the Division of Nursing-Bureau of Health Professions document characteristics of the people comprising nursing today (Division of Nursing-Bureau of Health Professions, National Sample Survey, 2001).

Registered Nurse Demographics

Preliminary findings indicate that there are an estimated 2,696,540 RNs in the United States as of March 2000. This represents a 5.4% increase from the 1996 survey, the smallest increase reported in previous surveys. Eighty-one percent of these RNs hold active licenses and are employed in nursing. Approximately 58.5% of this group are employed full time in the profession, with 23.3% of nurses working part time. In 2000 the average age of the RN population was 45.2 years, compared with 44.3 in the 1996 survey report. In 2000 31.7% are under 40 years of age, 18.3% under 35 years, and 9.1% under 30 years. Some speculate that the increase in the average age of RNs may represent the aging society or "second-career" nurses, with younger persons may be choosing other professions.

Although the profession continues to be predominantly female, the number of men working as RNs significantly increased in the past decade. The 2000 report indicates that the number of male RNs increased to 5.9%, up from 5.4% in 1996 data (Division of Nursing-Bureau of Health Professions, National Sample Survey, 2001).

Changes in racial/ethnic backgrounds were reported as well. The March 2000 survey reports that 86.6% of RNs are Caucasian/non-Hispanic, whereas 12.3% are nonwhite and ethnic minorities; 12.3% report being from one or more racial and/or ethnic backgrounds.

Changes also are occurring in the educational preparation of RNs. There has been a substantial increase in the number of nurses graduating from associate degree nursing programs during the past decade. Although not as dramatic an increase, baccalaureate-prepared nurses also are increasing in number. In 2000 graduates from basic nursing programs were 40.3% associate degree, 29.6% baccalaureate degree, and 29.3% diploma graduates. In March 2000 nurses reported their highest degree as 22.3% diploma, 34.3% associate degree, 7% baccalaureate degree, and 10.2% master's or doctoral degree (Division of Nursing-Bureau of Health Professions, National Sample Survey, 2001).

Advanced practice nurses now comprise 7.3% of the RN population, up from 6.3% in 1996. Nurse practitioners lead this group in numbers, followed by CNSs, nurse anesthetists, and nurse midwives. Nurse practitioners and CNSs make up 80% of the advance practice group. (Division of Nursing-Bureau of Health Professions, National Sample Survey, 2001).

Acute care hospitals remain the common worksite for RNs, although there has been a trend toward the outpatient settings. In 2000 59.1% of RNs reported working in hospitals. However, the area with the largest increase in employment was in community and public health settings—a total of 18.3%. About 10% work in physician-based practices, nurse-based practices, or health maintenance organizations (HMOs). Other worksites include educational settings, occupational health settings, nursing management, prisons and jails, and insurance companies (Division of Nursing-Bureau of Health Professions, National Sample Survey, 2001).

The Health Resources and Services Administration (HRSA) is part of the U.S. Department of Health and Human Services. The Bureau of Health Professions, a division of HRSA, provides national information on the health professions workforce in this country. See

24-3 for the website for the 2000 National Sample of Registered Nurses (NSRN), the most extensive source of statistics on the RN workforce

Hospital Opportunities

Despite enormous changes in hospital care, it seems evident that there will be jobs in the hospital environment for a long time. In the hospital the nurse in a direct-care role provides care for people who are ill and unable to provide for themselves. A function of the direct-care role also is to help the client and family in managing the illness event.

Depending on the region of the United States in which one lives, the degree of choice a new graduate might have in the clinical setting is highly variable. However, if the desired arena for work in hospital-based acute care is not available, it may be wise to accept whatever position is offered, with an eye to seeking an internal transfer as a position becomes available in an area of clinical preference. Such an approach is perceived as a willingness to be flexible and to learn. Accepting assignments in an open, cooperative spirit provides more opportunities for the beginning nurse to learn about the organization and gain important experiences. Further, working as a staff nurse offers many learning opportunities in addition to the immediate client-centered ones.

If the choice of the clinical setting has been based on experiences as a student, the new graduate needs to be prepared to have different perceptions in a new role. At a minimum, experiences that are highly enjoyable on the limited-time basis of a student schedule may feel different when the new graduate functions in that role full time. It also is good to have a mix of experiences and learning opportunities before making a definitive decision.

Misleading perceptions about functioning in various clinical arenas are not limited to new graduates. Often a person perceives or believes that one clinical area is the ideal choice, only to find that it is not what he or she wanted. For example, Jane Patrick, RN, wanted to work with sick children and successfully landed a position on the pediatric unit after a couple of years' experience as a staff nurse on an adult surgical wing. Despite her eagerness for the position, Jane found it difficult to adjust to the unit. The distress of the children in the unit was painful to her, and she found herself depressed and unhappy. She began to dream about the children for whom she was caring and was increasingly unable to provide nursing intervention that entailed discomfort for the child. Jane was not in the right place.

It is critical that nurses stay attuned to their reactions and respond in a constructive manner to discoveries such as Jane's. Internal transfers in large hospitals and medical center complexes are common; the probability is high that Jane will find a position that is deeply satisfying in another area.

In addition to clinical emphasis, nursing within hospitals offers almost endless opportunities for diversity. Staff level positions in a hospital can be on many different units, and working different shifts on those units presents different work environments, approaches to work, and priorities of client care. Some examples follow.

Infection Control.

The infection control nurse assesses the total incidence of infections within the hospital. Clients who suffer an infection while in the hospital are comprehensively reviewed to ensure prompt and accurate treatment and timely containment of the client's infection so that it is not passed to other clients or staff. The infection control nurse must also conduct a thorough analysis to determine the source of the infection and its onset. If the infection is determined to have been contracted during hospitalization, an investigation is initiated to assess the sequence of events leading up to the infection. A position such as this enables the nurse to have hospital-wide interactions and functioning. Knowledge of epidemiology and outstanding interpersonal skills foster full participation in the infection assessment process.

Quality Management. Although the parameters of a position in quality management or quality control vary from institution to institution, the basic premise is to ensure that outcomes in client care services are consistent with established standards. Benchmarking activities to establish such standards have been under way on a national level for the past few decades. Quality management nurses assess the compliance of the institution with established standards and explore variations from established standards. Chart reviews and ongoing interaction with the staff of the agency are integral components of a quality management position.

Specific Client Services. An almost endless list of specific client services can be found in hospitals, depending on the hospital's size and function within the community. Some nursing positions might be self-evident, such as the intravenous team on which the nurse provides support and interventions with the insertion and maintenance of intravenous therapies. Other services might relate to ostomy care, counseling, support groups, or health education related to a specialty area.

Coordinator Positions. Some hospitals have various coordinator positions such as trauma nurse coordinator. The nurse in this position is responsible for the coordination and integration of the clinical and administrative requirements of the trauma victim. Comprised of equal parts of program and case management, the trauma nurse coordinator role involves overseeing the care of the client from the point of injury through acute care to rehabilitation and back to society (Blansfield, 1995). Maintenance of a comprehensive database on the management of trauma victims is an important part of this position.

Another example of a coordinator position for a highly specialized area is the organ donor coordinator, who procures organs and oversees the transplantation program. Coordinators require considerable experience in the specialty in which they practice.

Variations on Traditional Roles in Nursing

As clients shift from hospital to ambulatory and home care, the role of the community nurse has evolved beyond the traditional public health nurse concept. Although they still have their basis in the framework of the traditional public health nurse concept, nurses today take their critical care skills into the home where clients recover from illness and surgery once only seen in an acute care setting. Pharmacologic and technologic advances make the care of chronic and critically ill clients in their homes a cost-effective option. For example, therapies such as dobutamine administration or chemotherapy were once considered "too risk/' for home administration. Today, adequate teaching of the client and family members and careful monitoring make these therapies a daily occurrence. Clients can be monitored through home visits by RNs, expanded technology, radiographs, or telemetry at home. Uterine monitoring for high-risk obstetric clients is common as vital signs of the mother and baby are observed by telephone modem. All these changes increase the need for home care nurses who are expert clinicians and client educators.

Hospice Nurse. As more clients with terminal illness choose to stop aggressive treatment, another nursing specialty has flourished. Over 3000 hospice programs exist in the United States today. The growth of hospice is seen by the 700,000 clients receiving these services in 1999. About 29% of all Americans who died in 1999 had hospice care, an increase from 1998 (NHO, 2001). Hospice and palliative care nurses treat the symptoms of those with progressive terminal disease. These nurses work holistically with clients and families to maximize their quality of life rather than focus on the quantity of life remaining. To learn more about the hospice concept, visit the website.

Informatics Nurse Specialist. As health care systems face the inevitable need for data management for decision making, another nursing role has emerged—the informatics nurse specialist. Nursing informatics (NI) is a nursing specialty whose activities center around management and processing of health care information. The Division of Nursing-Bureau of Health Professions defines the role of nurse informatics as "... combining nursing science, information management science, and computer science to manage and process data, information, and knowledge to deliver quality care to the public, particularly disadvantaged and underserved populations" (National Informatics Agenda, 2001). Recommendations by the National Advisory Council on Nurse Education and Practice (NACNEP) commissioned a panel of experts to advise them in setting the direction needed for NI in this country. For the executive summary of their recommendations, visit their website.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recognized the increased need for information management in the clinical client care settings. In 1994 JCAHO standards on information management define management information as critical to organizational success. Nurses are well positioned to assume these roles as they best understand client care processes. Certification is available through the American Nurses Association (ANA) to support this role. The ANA defines informatics as "the activities involved in identifying, naming, organizing, grouping, collecting, processing, analyzing, storing, retrieving, or managing data and information" (ANA, 1994). The ANA Infomatics Association has an information website.

Occupational Health Opportunities. Nursing within the framework of specific occupational groups has long been a career option for nurses. Within these settings the nurse designs and implements a program of health promotion and disease prevention for employees and assists with immediate health needs as necessary. In this primary care milieu the nurse assesses the need for programs about specific topics of importance to the health of the employees. Some examples of these might be breast-screening programs for female employees and information on early identification of prostate cancer for male employees. Other programs might revolve around the management of developmental events such as empty nest syndrome, menopause, caring for aging parents, or retirement.

In addition to services related to maintaining the health of employees, the occupational nurse is responsible for the assessment of the work environment to ensure the safety of the employees. Examples of work that has been significant in improving the health of U.S. workers are clean air programs, anti-smoking-on-the-job campaigns, and requirements to eliminate the use of asbestos in heating or insulation of buildings. All of these activities pose special challenges to the occupational health nurse. The nurse in these settings develops procedures to be followed in the event of illness at work, including the management of emergencies.

There also are opportunities in specific industries such as the airline industry. Within the airline industry it is the responsibility of the nurse to contribute to airline safety through maintaining the health of employees. Protection of the employee's health is a component of the role, and of equal concern is the impact of the health of the employee on the safety of the airline and its passengers (Zimmerman, 1996). The nurse must be vigilant in the assessment of employee health problems that could affect overall airline safety. An obvious function is alcohol and drug screening. Protocols for the maintenance of employee health programs in the airline industry must be strictly followed and enforced, as required by government regulation.

Nonetheless, the heart of this nursing position still lies with providing care to people, which sometimes can place the nurse in a difficult position. In the ongoing monitoring of the health of the employees, the nurse often is the first to spot the development of a deviation from health that could affect the career and livelihood of an employee. Such an example is hypertension; if an employee is developing high blood pressure, which will affect his or her employment status, that employee can apply pressure on the nurse to "hear" the blood pressure in the qualifying range.

Morris (1996), who works in an airport health center, perceives that her work is distributed in the following manner: 75% is devoted to administrative activities, 15% to education, and 10% to clinical practice. In this particular center the occupational health and employment screening activities are entwined with urgent care and travel assistance for passengers. Although occasionally an emergency situation develops with a passenger or an employee, most of the client problems are travel-related. For example, international travel to some countries requires comprehensive precautions regarding immunizations and inoculations. In addition, passengers may forget prescribed medications, or medications may be lost in baggage. Shortterm problems such as fear of flying also are managed within such a clinic.

Another form of transportation provides a career opportunity: cruise ship nurse. Generally, when people think of a cruise, they do not think of getting sick or getting a job; however, some of the cruise ships in existence are like small cities. One nurse, Wrobleski (1996), describes being the chief nurse on a liner with 2000 passengers and 900 employees. The role of the nurse in this setting is similar to that of the airline nurse with respect to the health of the employees and the safety of the passengers. The unique elements of the ship relate to special sanitation requirements such as testing and culturing the water supply and managing the total health needs of the passengers. It also is the nurse's responsibility to instruct the staff on the basic elements of emergency care and transport. Primary patient care needs are similar to those found in an Emergency Department.

Quality Manager. Another role that is becoming more attractive to nurses is that of quality manager. This reflects the need for health care providers to assess opportunities for process improvement, implement changes, measure outcomes, and then start the improvement process over again. Quality management nurses research and describe findings and look for opportunities to improve care. The result of quality studies may produce critical pathways or algorithms defining care and expected client outcomes. Basic and advanced knowledge of quality management tools is essential, although practice may vary from setting to setting. For instance, in the inpatient setting the quality management nurse needs strong clinical skills as might be acquired in medicalsurgical practice, intensive care units, or the operating room. Experience in home care would be an advantage for a quality management nurse in that setting. Interpersonal skills are important because to be successful this role requires building relationships and rapport. The role of quality manager is one that promotes improved care for health care recipients in a variety of settings. Visit the quality management websites for more information (see


Case Manager. This role has had a rich tradition in community and public health nursing, and it recently has been gaining more prominence in acute care. Case managers coordinate resources to achieve health care outcomes based on quality, access, and cost. The complexity of case management practice is obvious in the era of chaotic systems caused by recent changes in the health care market in which providers, services, and coverage details are constantly changing. Case managers identify the best resources at the lowest cost to achieve the optimum health outcome for the client (Stanhope and Lancaster, 2000).

Flight Nurse. Flight nursing is a specialty for nurses who desire autonomous practice and the opportunity to use advanced clinical skills. Practice is as diverse since clients are all ages and from all backgrounds with different health problems. Critical care experience, with certification in advanced cardiac life support, is necessary. Most programs prefer experienced nurses in critical care and/or Emergency Department nursing. The two types of flying practice available are military, such as in the Air Force Reserves or active duty, and civilian flight nursing. Visit the website So, You Wanna Be a Flight Nurse (

24-3) to learn more. Nurses who enjoy a fast-paced diverse practice in an unstructured setting may find this role a good fit for them. For more information, call the Air and Surface Transport Nurses Association, formerly known as the National Flight Nurse Association, at 1-800-897-NFNA (6362) or visit their website (see

Telephone Triage Nurse. Another emerging career is that of telephone triage nurse. In this practice nurses interact with clients on the telephone to assess needs, intervene, and evaluate. This position requires excellent communication and assessment skills, as well as problemsolving skills. Telephone triage is used in a variety of settings, including Emergency Departments and physician practices.

Forensic Nurse. Forensic nursing may well be one of the fastest-growing nursing specialties in the twenty-first century. This is likely due to the United States' epidemic increase in violence and resulting trauma. The ANA's Scope and Standards of Forensic Nursing Practice, published by American Nurses Publishing, serves as a professional guide for nurses working in or entering this evolving specialty. Forensic nursing applies nursing science to public or legal proceedings in the scientific investigation and treatment of trauma and/or death of victims of violence, abuse, criminal activity, and traumatic accidents. The nurse may provide direct services to individual clients, as well as consult with and/or be an expert witness for medical and law enforcement. To learn more about this exciting practice, visit the International Association of Forensic Nurses (IAFN) website (see

24-3). The American Forensic Nurses' Organization offers distance-learning programs through the Internet (see their website in

Oddsei - What are the odds of anything.