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Nursing offers opportunities for a wide range of professionals, from unlicensed nursing assistants who have only on-the-job training to clinical specialists and administrators with graduate-level education and extensive training. Nursing professionals provide a variety of services in a multitude of settings, from community health agencies, hospitals, and extended care facilities to the military, other federal nursing agencies, and industry. Nurses assist individuals, families, and the community by improving, sustaining, or restoring health. Such work requires extensive preparation and training in specialized scientific areas and other academic fields, inquiry and communication expertise, and strong social skills.

While thirty years ago a nurse in the United States advanced mainly through job performance, present requirements for upward mobility differ. Today, education is the key to career advancement. As there is a great need for employees on all levels of health care delivery, individuals should consider their personal and professional goals and interests when choosing a particular educational path. Discussed below are types of educational programs in nursing presently available in the United States.

Practical nursing programs. A licensed practical nurse (L.P.N.) program involves one to one and a half years of nursing training at a state-approved vocational technical school or community college. There are approximately 1,250 state-approved L.P.N. programs in the United States. Most require a secondary school diploma or the equivalent for admission. After passing state board exams for L.P.N. licensure, a graduate is prepared for immediate employment in a hospital. The L.P.N.'s responsibilities, however, are more limited than those of a R.N., and the prospects for upward mobility remote.

Registered nurse preparation. Three educational paths exist to become a registered nurse (R.N.). These include the two-year associate degree program, the three-year diploma program, and the four-year baccalaureate program.

Aassociate degree. An associate degree provides limited career opportunities for the nursing professional; such programs do not prepare a nurse for leadership or administrative roles or for positions in community health nursing. While the majority of associate degree programs are available at community and junior colleges, some senior colleges and universities, technical institutes, and private institutions also offer these programs. Minimum requirements include completion of secondary school education. Programs last two academic or calendar years, combining nursing courses and supportive college courses, and award either an A.A.S. (Associate of Applied Science) or an A.S. (Associate of Science). Upon completion of a state-approved program, a graduate is eligible to take the state licensure examination to become a registered nurse. To obtain a bachelor's degree after receiving the associate degree, a student may have to spend longer than two years and repeat some material.

Diploma programs. Although hospital diploma schools are the oldest type of educational program preparing R.N.'s, programs have declined in number from 800, twenty years ago, to about 130 today. A diploma program lasts three academic or calendar years. Entrance requirements include secondary school graduation. Academic credit is not awarded for course work. Graduates of state-approved diploma programs are eligible to take the state licensing examination for registered nurses. After receiving the R.N. license, diploma graduates are limited to beginning hospital staff positions as health care generalists and are not qualified for certain positions outside the hospital. This type of program is suited for individuals who desire education involving early patient contact that continues throughout training.

Baccalaureate degree. A baccalaureate program in nursing, undertaken at senior colleges and universities, lasts four years. Minimum admission requirements include a secondary school diploma and college entrance examinations. Nursing programs may have requirements for entry in addition to what is required for entry to the overall college or university. Nursing baccalaureate study combines education in the theory and practice of nursing with general education in the humanities and behavioral, biological, and physical sciences. Upon completion of a state-approved program, graduates may take the R.N. state licensing examination.

Students who already possess a nursing license (having received education through an associate degree or diploma program) generally follow a special curriculum called an articulated baccalaureate program, which lasts less than four years. Admission requirements may include a year or more of experience, and course work is likely to concentrate on community health, management and leadership, health assessment, and other areas not usually included in previous education. With the baccalaureate degree in nursing, either a B.A. (Bachelor of Arts) or B.S. (Bachelor of Science), and the R.N. license, nurses are prepared for positions in administration and advanced nursing as well as in community health. The degree also provides the basis for graduate education, which allows for greater career opportunities as teachers, clinical specialists, administrators, or researchers.

graduate level. At the graduate level, nursing professionals prepare for specialization in a variety of areas. The top-level and highest salaried positions in nursing are obtained only with master's and doctoral degrees. Most graduate study is offered at the master's level, although the number of doctoral programs is increasing.

Master's degree. The master's program, which requires at least one year of full-time study, prepares graduates for positions in clinical practice, teaching, research, administration, and consulting. Enrollment in master's programs is expected to increase as the demand for nurses with advanced degrees grows. The curriculum generally includes three components of advanced study: research, theory, and nursing practicum and courses supportive of the individual's area of specialization, which may include such areas as maternal-child nursing, medical-surgical nursing, gerontological nursing, psychiatric nursing, or public health. Admission to a master's program requires a baccalaureate degree, usually from an National League for Nursing (NLN)-accredited program, and often R.N. licensure and practical nursing experience as well as the Graduate Record Examination or other admissions tests. Degrees obtained are the M.N. (Master of Nursing), M.S.N. (Master of Science in Nursing), and the M.A.

Doctoral degree. Presently, two types of doctoral programs are available: a program where nursing is the major field of study, and a program where the major field of study is in the area of the physical, biological, social, or behavioral sciences. Admission requirements include baccalaureate and master's degrees in nursing; licensure and experience are also common requirements. Doctoral programs prepare nurses to become faculty members at universities, deans of nursing schools, medical center administrators, researchers, expert clinical practitioners, and consultants. Doctoral program length varies. The degrees offered are the N.D. (Doctor of Nursing) -- the professional doctorate; the D.N.S. or D.N.Sc. (Doctor of Nursing Science) -- the advanced clinical doctorate or the clinical research doctorate; and the Ed.D. (Doctor of Education) -- the education doctorate.

Specialization. Nursing specialties exist in a wide range of areas, including oncology nursing, medical-surgical nursing, pediatric nursing, obstetric nursing, and critical care nursing. There are specific requirements for certification in nursing specialization that are determined by the particular specialty.

Specialization is obtained in several ways: through degree certification, continuing education, or on-the-job training. To qualify for a nursing specialization one or a combination of the following requirements may apply: completion of a certificate program, graduation from a master's program, and passage of a specialty licensing examination in addition to the R.N. licensure.

Educational programs are offered by hospitals, medical schools and nursing schools. Some programs award a certificate, others award a master's degree. A certificate program may last only eight months, whereas a master's program will usually last one to two years. For some specialties, such as nurse midwifery, a combined R.N./master's program is available to non-nurses who have a baccalaureate degree. This program involves twelve months of intense nursing training, after which the student is eligible to take the R.N. licensing examination. After passing the R.N. licensing exam, the student then chooses a specialty and enters the master's program in that area.

Specialization at the graduate level may be according to clinical area (e.g., community health nursing, medical-surgical nursing, psychiatric nursing); age group (child health nursing, adult health nursing); or functional area (teaching or administration).

"Peterson's Guide to Graduate Programs in Business, Education, Health, and Law" provides descriptions of the following areas of specialization available through graduate studies: child-care nursing, gerontological nursing, maternity nursing, medical-surgical nursing, nurse anesthesia, nurse midwifery, nurse practitioner studies, nursing administration, nursing education, oncology nursing, psychiatric nursing, public health nursing, and rehabilitation nursing.

In certain states, nurses are required by law to keep their skills well-honed through ongoing education. Continuing education, also a requisite of most nursing specializations, is often measured according to contact hour, as recommended by the American Nurses' Association. The contact hour is defined as fifty minutes in an approved learning experience. The continuing education unit (CEU), which consists of ten contact hours, is the standard unit of measurement for certification in particular nursing specialties. For example, a nurse may be required to have fifteen CEU's (150 contact hours) in critical care nursing before certification for that specialty is granted.

Accreditation. The National League for Nursing (NLN) is the only accrediting body for general nursing programs recognized by the Council for Postsecondary Accreditation and the US Department of Education. (One accrediting body for specialty programs, the American Association of Nurse Anesthetists, is also recognized by both organizations.) The NLN accredits practical nursing programs and associate, diploma, baccalaureate, and graduate degree programs. Students are advised to check a program's accreditation status prior to enrollment.

CGFNS Certification and licensure. As noted above, many graduate degree programs in nursing require applicants to be licensed as registered nurses. A few programs may waive this requirement for foreign nursing school graduates licensed in their home country, but generally these nurses will be required to obtain certification from the Commission on Graduates of Foreign Nursing Schools (CGFNS). They will also often be asked to achieve US licensure before they can take part in the clinical practicum that is generally included in their curriculum.

CGFNS certification is also essential for foreign nurse graduates who want to work in the United States. Foreign nurse graduates who hold the CGFNS certificate are eligible to apply for a nonimmigrant or H-1 visa and a labor certificate (or work permit). This work permit is a requirement to obtain immigrant occupational preference visa status.

The CGFNS certificate is also required by the majority of state boards of nursing before the foreign nurse graduate can take the National Council Licensure Examination for Registered Nurses (NCLEX-RN) and gain US licensure. The first part of the CGFNS certification process involves a review of the applicant's educational credentials and home country licensure status. If the foreign nurse graduate is judged to have an educational background comparable to that of a US nursing school graduate and possesses current and valid licensure nursing licensure in his or her native country, the applicant becomes eligible to take the CGFNS Qualification Examination.

The CGFNS test is a one-day examination that assesses an applicant's basic level of knowledge in nursing and English. The purpose of this screening exam is to identify and predict which foreign nurse graduates have reasonable assurance of passing the NCLEX-RN in the United States. The English portion of the CGFNS exam is one hour long and tests an applicant's level of listening comprehension and correct usage of English vocabulary and sentence structure. Eight to ten weeks after the exam, CGFNS notifies all applicants whether they have passed or failed. If they have passed, they receive CGFNS certificates. If they have failed, they can reapply to take the exam as many times as necessary. Details on the CGFNS application process are provided by the "CGFNS Guidebook for Applicants," available free from CGFNS.

In the Moscow EAC, we have copies of "Path to CGFNS Certification: Applicant Handbook" which explains the procedures to become certified. For more information, contact:

CGFNS certificate holders who decide to pursue a nursing career in the United States need to apply to take the NCLEX-RN exam by writing directly to the nursing board in the state where they intend to practice. Eighty percent of the states require applicants to have the CGFNS certificate before they can sit for the licensure exam. Fifty percent of state boards will waive their own review of credentials for foreign nurse graduates who hold CGFNS certificates.

CGFNS sends everyone who passes a list of state nursing boards. Applicants may, however, wish to spare themselves delays in the licensure process by doing their own research and writing state boards while they wait for their results on the CGFNS exam. The NCLEX-RN licensure examination is used by every US state. It is a six-hour examination administered over a two-day period that tests nursing knowledge through multiple-choice questions depicting clinical situations that an entry-level nurse might face.

Other requirements for licensure may differ from state to state. Each state board can provide information on its own requirements.

Titles. Confusion often occurs over the variety of titles applied to nursing professionals in the United States. Levels and types of nursing range from nursing assistant, L.P.N., and R.N., to visiting nurse, public health nurse, and clinical specialist. The following clarifications provide basic details on several of the most commonly known titles for nurses, from lower-level positions to the highest-level professional opportunities.

NURSING ASSISTANT: Other titles at this level include orderly, hospital assistant, geriatric aides, psychiatric aides. On-the-job training is required, usually from six weeks to three months; a license or standardized examination is not required; work is in an institution or in the patient's home under the supervision of a registered nurse.

LICENSED PRACTICAL NURSE (L.P.N.) in California and Texas known as a licensed vocational nurse (L.V.N.): A graduate of a state-approved school of practical nursing who has passed the state board examination for practical nursing; requires an educational program usually of one year at a vocational technical school. L.P.N.'s do not have the education to provide the skilled care an R.N. provides. Most work in hospitals, nursing homes, doctors offices, and deliver routine bedside care, under the direction of a physician or a registered nurse.

REGISTERED NURSE (R.N.): A graduate of a state-approved school, either from a two-year associate degree program, a three-year diploma program, or a four-year baccalaureate program, who has passed the state board licensing (NCLEX-RN) examination for R.N.'s. License must be renewed periodically, with continuing education a legal requirement for license renewal in certain states.

NURSE PRACTITIONER (N.P.): An R.N. with advanced training, a high level of technical skills, and usually a master's degree. An N.P. specializes in an area such as pediatrics, geriatrics, family health, or midwifery, and performs certain duties previously reserved for physicians: history taking, physical assessment, prescribing medication. Each state regulates N.P.s.

CLINICAL SPECIALIST: A practitioner of advanced nursing who usually possesses a master's degree in one specialty area. Clinical specialists direct nursing care and advise nurses, unlike N.P.'s, who work closely with physicians and often make medical decisions. Clinical specialists also work in research positions and as consultants to other groups in a hospital.