If you are a registered nurse or LPN/LVN looking to take the next step in your career, you should certainly consider an advanced practice degree and the steps to become a nurse practitioner.

According to April Kapu, President of the American Association of Nurse Practitioners, an advanced practice degree is all about “continuing to build upon the education you have to create more opportunities…It’s about creating opportunities and reaching people in different ways throughout your career.”

For Kapu, a holistic approach to patient care is basic to nursing practice at all levels, “taking into consideration…where [patients] live, where they work, their transportation, their access.” This same holistic lens shapes the NP role. “As a nurse practitioner, we diagnose, we prescribe pharmacologic and non-pharmacologic therapies, we coordinate care with everybody on the healthcare team.”

And patients are responding, she notes, by increasingly indicating a preference to be seen by NPs, even when MDs are in-clinic as well. This preference has also been observed by Karen Perion, an adult-gerontological and acute care NP. Patients “feel more at ease; they feel more collaboration [and] more advocacy” from NPs. For Perion, “advocacy, collaboration, and communication” are the three key things she learned as a bedside nurse, and these are also the goals she brings into her NP practice each day.

The Need for Nurse Practitioners

But it’s not just about having a fuller engagement with the care of individual patients. NPs also reach many millions of patients who would otherwise struggle to find care at all.

According to Kapu, 89% of new NPs are certified in primary care. This ratio has remained constant even as the number of practicing NPs has exploded in recent years, from 148,000 in 2010 to 222,000 in 2016, to 355,000 by Spring of 2022. These numbers make clear how NPs have stepped in to fill the substantial and growing shortage of primary care physicians in the U.S.

In fact, by last year there were more NPs licensed for primary care than there were primary care physicians, who now make up only about 30% of all MDs. But the current physician shortfall extends well beyond primary care. Rural areas of the U.S. are now deeply under-served by both general practitioners and specialist physicians. Another clear barrier to care is economic — many physicians are unable to accept Medicaid, while many Americans on Medicare struggle to find primary care physicians and specialists accepting new patients.

It is no surprise, then, that NPs are in particular demand in rural America and, over 80% of NPs accept Medicare and Medicaid patients.

Education To Become a Nurse Practitioner

Of course, the enhanced clinical responsibility of the NP role requires further education and certification. Many RNs are already increasing their career opportunities by going beyond the Associate Degree to a four-year BSN. The next step would be a Master of Science in Nursing, typically requiring another 18 to 24 months of study beyond the BSN level.

But practical nursing experience still plays a central role in advancing one’s formal nursing education. As Karen Perion emphasizes to her own nursing students at Harper College near Chicago, students who attain their associate’s degree in nursing should put in at least a year of practical bedside nursing before they consider a bachelor’s degree and probably even more before considering a master’s degree. “You’ve got to get your feet wet; you’ve got to figure out what’s your passion — what exactly do you want to do within nursing?”

After all, an advanced practice nursing degree opens up a host of specialties within the NP role. Aside from primary care, NPs can specialize in acute care and gerontology, pediatrics, psychiatric care, women’s health and other areas. Typically, these require choosing your specialty at the start of your graduate coursework, and both that choice and the coursework will make a good deal more sense if it’s grounded in practical, bedside nursing experience in that specialty.

Finally, for those nurses who want to make a difference in their field beyond individual patient care, the final step would be a doctorate in nursing practice. DNPs play advanced roles in nurse leadership as well as research and teaching. As Kapu says, “We want nurses to lead in every space: we want nurses to be on boards and in government. We want them to lead hospital and executive teams. And that’s where the doctorate really comes into play.”

Next Steps and Financial Aid

Of course, many working nurses considering an NP path will be concerned about tuition expense. But Kapu emphasizes that there are now very considerable financial-aid resources available to nurses, in the form of scholarships and fellowships, grants, and loan-forgiveness programs, offered not only by nursing schools but also by healthcare employers themselves as the need for advanced practice nursing becomes increasingly clear.

The pressures on new graduate nurses to transition from education to practice are often too much to take, causing registered nurses (RNs) meant to fuel nursing’s workforce pipeline in the coming decades to question their career choice.

One thing that can ease the transition and help retain new nurses is nurse precepting, said Solimar Figueroa, PhD, RN, MHA, P-PCA, a clinical collaborator for the American Academy for Preceptor Advancement (AAPA).

But precepting bedside nurses isn’t what many think and nurses who want to become preceptors should learn how to properly do it.

Although mentorship is a relationship that can last for much of a mentee’s career and occurs when an experienced nurse guides the professional journey of another nurse, preceptor ship is an official relationship, designed in a limited time to evaluate new nurses and offer feedback that helps them gain traction in their practices, according to Figueroa.

Figueroa is a speaker for the Nurse.com Preceptor Specialty Practice, a continuing education course that teaches nurses how to get the most out of their precepting experiences. The course fulfills one of the requirements for the AAPA’s Preceptor Specialist Certification.

Less Confident; Less Competent

In nursing’s early years, charge nurses were preceptors. Diploma-prepared nurses would learn at the bedside, with more experienced nurses teaching them, according to Figueroa.

“There’s a huge discussion about the gap between education and practice. When new nurses graduate, they’re less confident and less competent,” she said. “What’s really happening with these new nurses coming in is they’re not prepared to handle a full patient load. So, they have what we call a reality shock, thinking things like ‘I wasn’t prepared this way. This isn’t what I’ve learned.’ Then they start questioning whether they have decided on the right profession.”

To ease the predicted nurse shortage in coming years, the National Academy of Medicine recommends healthcare employers offer new nurses structured nurse residency programs. Preceptorship is part of nursing onboarding residency programs, and trained preceptors are vital for giving new nurses needed confidence and increase nurse competence, according to Figueroa.

“But that’s not going to happen if you don’t have preceptors, or experienced nurses, teaching these new nurses,” she said. “If your preceptors are not adequately prepared and supported, then your residency program will suffer.”

Experienced nurses have a responsibility to consider precepting as part of what the American Nurses Association (ANA) says is nurses’ social responsibility to protect and uphold the well-being of the populations they serve, Figueroa said.

“As a preceptor, you ensure every new nurse to become confident and competent to deliver quality care. That means you’re ensuring the safety of the patients — the population you serve. So, it’s actually answering to the call of our social responsibility as a nurse,” she said.

Being a Good Teacher Is One Thing — Precepting Is Another

Preceptor certification is a nurse’s way to show he or she is an expert, Figueroa said.

“It’s really important that we’ve certified preceptors that follow the scope and standards of precepting,” she said.

Employers often compensate preceptors or consider the role a way for nurses to climb clinical ladders. But there are no universal guidelines for compensating nurse preceptors and nurses should inquire about potential benefits or advocate for adequate compensation if there isn’t any, according to Figueroa.

Precepting 101

The Nurse.com course covers topics needed for successful precepting, such as boundaries between preceptor and preceptee, critical thinking, communication skills, delegation, time management, evaluation of competency, goal writing, constructive feedback, patient/family engagement, and more.

Tammy Franqueiro, RN

Tammy Franqueiro, MSN, RN-BC, CENP, Vice President of Versant, a healthcare competency solutions company, and a speaker for the Nurse.com precepting course, said there are many skills useful for nurse preceptors. Among them — giving feedback.

“Feedback helps the preceptee to develop knowledge, skills, and attitudes and establishes the expected performance,” she said. “Feedback should be objective, specific, timely, informal, and done privately,” Franqueiro said. “Be able to flex your teaching style. Be creative, innovative to match your preceptee’s learning needs and experience level.”

Preceptors, according to Franqueiro, should employ multiple approaches to encourage preceptees to think critically and integrate the knowledge into their practice. One of those is to assist preceptees in establishing SMART goals — specific, measurable, attainable, relevant, timely.

“Establish timelines for goals, objectives and outcomes throughout the preceptorship with clear performance expectations specific to the individual,” Franqueiro said.

Experienced nurses who want to hone precepting skills should think back to their first orientations, according to Franqueiro.

“Whether you had a positive support system, were left to figure things out on your own, or worse yet, had a toxic coworker as a preceptor — whichever the situation, use that memory and learn from it to become the preceptor every preceptee wants to work with and learn from,” Franqueiro said.

Most nurses rank salary as the number one aspect of job satisfaction. Yet less than half of RNs say negotiating salary is something they always do at the start of each new nursing job, according to the Nurse.com Nursing Salary Research Report.

More than 7,400 registered nurses from all 50 states, working in a wide range of settings, responded to online survey questions last summer. The data revealed salary was the No. 1 compensation factor for all RNs in relation to job satisfaction, followed by their ability to use their full scope of practice. Nurses also said the mission of the organization, advancement opportunities, regular merit increases, tuition reimbursement, and overtime opportunities were what they looked for most in a job.

Although APRNs (61%) and LPNs (61%) were more likely to negotiate their salaries, only 46% of RNs say negotiating salary is something they do all or most of the time. Almost half of all nurses surveyed said they never or rarely negotiate their salaries, even though negotiating salary can result in a higher compensation. And men and non-binary individuals negotiate salary more often than women.

How much wiggle room do nurses have when it comes to negotiating salary? And how should they go about it?

Ask About Pay Structures When Negotiating Salary

Theresa Mazzaro, RN

Salary negotiations are worthwhile and may be possible for experienced nurses seeking new jobs, but not likely for new nurses, according to Theresa Mazzaro, RN, CHCR, senior talent acquisition specialist at Suburban Hospital, in Bethesda, Md., part of Johns Hopkins Medicine. She also serves as a member of the board of directors of the National Association for Health Care Recruitment.

The reality is there are many factors that impact how much employers can vary on nurses’ and other providers’ salaries, according to Jessica Quezada Jackson, CHCR, a talent acquisition recruiter at a health system and NAHCR board member.

In a unionized environment, for example, the union determines employment parameters, including salary. But even in the absence of a union, employers like hospitals have to abide by Affirmative Action and U.S. Equal Employment Opportunity Commission guidelines, which promote equity in hiring practices, according to Jackson. Many employers pay nurses based on level of experience, with tiers built in for certifications, higher degrees and more. It’s not really a negotiation, according to Jackson, but rather a set tiered pay structure.

The most important thing nurses can do to make sure they’re leveraging their experience, education and more is to understand a potential employer’s pay structure, so they can negotiate where possible, Jackson said.

“Nurses can get that information through their recruiters,” she said. “A lot of recruiters are in-house, and they’ll be able to tell you what you’re going to make based on your background.”

New Graduate Nurse Pay

Jessica Quezada-Jackson

For new graduate nurses, there is typically no negotiation, Mazzaro said.

There are numerous factors that can affect a new RN’s salary. Credit for previous LPN experience is one factor that goes into the calculation of the new nurse’s base salary. The education level of the new graduate also might help that nurse earn more. Registered nurses with an associate degree in nursing might have a different starting salary than one entering the workforce with either a BSN or entry-level MSN, according to Mazzaro.

There are other ways to earn higher pay, even for a new nurse. Like a more experienced nurse, a new graduate nurse might be able to earn a differential if he or she works the night shift, versus the day shift.

Experienced Nurses’ Negotiating Power

An experienced nurse might have greater negotiating power.

Some employers have policies where they pay according to a pay scale, based upon years of experience in that nursing specialty. There is no room for negotiation or discussion, according to Mazzaro.

That’s why it’s important for experienced nurses to make sure their experience and the value they might bring to a new role is clear.

“From a negotiation standpoint, it would behoove the nurses to be able to tell their stories about the experiences of jobs they’ve had and what they’ve done,” Mazzaro said. “Because if we’re looking at just a resume and that’s the only snapshot we have when we’re calculating a salary, we might not have the whole picture.”

It’s also important to think about overall pay and compensation when starting a new job, according to Jackson. For example, nurses who are relocating to underserved areas may be able to negotiate more lucrative relocation packages versus higher base salaries.

Prepare Now for a Higher Salary Later

Nurses can work on boosting their salary potential at their current and future jobs in several ways, including becoming certified in their specialties.

“Getting that certification shows and proves via an evaluation and exam that you are competent and certified as a specialty nurse,” Mazzaro said.

And that could lead to an increase in pay at a current job or a higher starting pay at a new job.

Salary increases and education levels often go hand in hand, experts say. Nurses with associate’s degrees, for example, should ask their employers if they pay more for a BSN and, if so, how much more. Sometimes the increase in pay for higher education is a differential, added to a nurse’s pay; sometimes, it’s worked into the base salary, according to Mazzaro.

“The other thing I would recommend to nurses is to become a preceptor or a charge nurse,” Mazzaro said. “Anytime that you increase your level of responsibility, like with being a preceptor or a charge nurse, there’s typically a differential for that.”

Mazzaro said it’s usually best for nurses to talk about pay with their recruiters and not hiring managers.

“Work with your recruiter and make sure your resume is complete and up to date, especially for those nurses who are highly tenured and have lots of years of experience,” Mazzaro said. “The more you can diversify and expand your knowledge base and skill set, the more opportunity you do have to ask [for higher pay].”

A long-term care nurse shared that her facility was accused of negligence in failing to use bed rails properly to prevent residents from falling out of bed.

The report was denied by the organization. As a result, the RN was asked to complete an assessment of the entire facility for bed rail use. The RN did the assessment and documented her results.

According to the RN, the administrator told her bed rails were not to be used to define the parameters of a resident bed, and that if the bed rails were being used to prevent a resident from falling, they should be removed.

A resident’s family member raised a concern about the removal of the bed rails from her sister’s bed. The administrator denied that the bed rails were removed intentionally by staff. The resident was found deceased on the floor the next day, and the RN was asked to change her documentation of her assessment. She refused.

Subsequently, the RN was confronted by the administrator who said she had failed to do the assessment (although the RN says she found her assessment in the facility shredder box). The RN was also accused of not updating patient care plans, but she stated she had, in fact, done this and had taken screen shots of her updates. The administrator had another RN change the documentation done initially by the RN in question.

Three days later, the RN was terminated. Her question is whether or not she should report the facility and those involved.

Consulting an Attorney

The first step for this RN should be to seek a consultation with a nurse attorney or attorney whose practice consists of representing nurses and other staff in long-term care.

A consultation is essential not only in fashioning a report about the facility, but also to protect the RN. The submitted question is not entirely clear, and the facility’s motivation for removing bed rails (if the RN’s account is accurate) is quite disturbing.

What seems apparent is that there was an attempt to make the RN cooperate with the administrator and the other nurse in concealing the initial mandate to remove bed rails and in the death of the resident due to the bed rail situation.

The attorney will most likely discuss the federal Nursing Home Reform Act with the RN. This act requires that nursing homes provide quality care, protect residents from all forms of abuse and neglect, and spell out residents’ rights. Any nursing home receiving Medicare or Medicaid funds must comply with these standards.

In addition, the attorney will also review the state’s nursing home care act with the RN. This act and its official name may vary from state to state, but like the federal law, it lists residents’ rights and protects them from abuse and neglect.

Each act contains provisions for the enforcement of the act’s requirements when a violation occurs and where the violation is to be reported. For a list of each state law, click here.

Protecting the Nurse

The attorney will also focus on the RN’s conduct in order to protect her legally. The RN has evidence of her following the mandates of the administrator in assessing the bed rail situation and the documentation in patient care plans.

This evidence can be used in any legal forum, including a case filed by the deceased resident’s family against the nursing home or in a professional disciplinary hearing by the state board of nursing, if the nursing home files a complaint against the long-term care nurse for somehow contributing to the resident’s death.

The RN’s refusal to change her initial documentation and the fact that another RN changed her documentation (supported by the RN’s discovery of her copy in the facility shred box and her screen shots of the care plan updates she made) bodes well for her in any legal proceeding.

It appears that the RN has substantial, credible information about the conduct of the nursing home administrator and the nurse who changed her initial documentation.

Under the RN’s state nurse practice act and rules, the attorney will inform the RN that she has a duty to report the administrator to the board of nursing or other board that regulates nurse administrators and to report her RN colleague to the state board of nursing.

It is unfortunate that the long-term care nurse was terminated from her position at the facility. This is an outcome that often occurs when a nurse attempts to adhere to applicable ethical and legal standards of nursing practice.

If you find yourself in a similar situation, remember that you are accountable and responsible for your actions. Despite an end result of losing one’s job, be reassured that refusing to participate in any mendacious conduct is a reward that will continue to follow you in your future practice.

Nursing represents the largest healthcare profession in the U.S., with more than 3 million active licensed registered nurses (RNs) working in the country.

These highly regarded professionals rose to the challenges brought on by the COVID-19 pandemic, and the nation took notice by rating nursing the most honest and ethical profession for the 20th year in a row, according to Gallup.

“Nursing is an excellent profession to choose for a number of reasons,” said Rebecca J. Graves, PhD, NP-C, Associate Professor and Director of Special Projects and Evaluation, College of Nursing at University of South Alabama, in Mobile, Alabama. “Most importantly, it is incredibly rewarding to be able to help others every time you go to work.”

Another reason to become a registered nurse is that RNs are in high demand. RN employment is expected to grow 9% from 2020 to 2030 or by 194,500 job openings annually, according to the U.S. Bureau of Labor Statistics (BLS).

Follow these steps for how to become a registered nurse and start your journey toward a satisfying, meaningful career.

What Is a Registered Nurse?

A registered nurse is, “An individual who has graduated from a state-approved school of nursing, passed the NCLEX-RN examination, and is licensed by a state board of nursing to provide patient care,” according to the National Council of State Boards of Nursing (NCSBN). Becoming a registered nurse means taking on the incredible responsibility of caring for the loved ones of others, helping them heal, and advocating on their behalf.

What Does a Registered Nurse Do?

In essence, RNs:

• Provide and coordinate patient care as part of a team of healthcare providers and clinicians
• Educate patients and the public about health conditions
• Provide advice and emotional support to patients and their families

These broad definitions, however, do not capture the vast array of a nurse’s responsibilities and the talents they require. Their talents are why nurses are highly sought after for a variety of settings. To start, RNs can work for:

• Hospitals
• Skilled nursing facilities
• Long-term care facilities
• Ambulatory and outpatient clinics
• Private practices
• Schools
• Correctional facilities
• Home health agencies
• Telehealth providers
• Insurance companies
• Addiction centers
• Mental health facilities

The list goes on and on.

“’Patient care’ is a term that accompanies many actions and may be defined differently according to the setting in which the RN practices,” said Graves, who cited the sequential nursing process from Nursing Process by Tammy J. Toney-Butler and Jennifer M. Thayer. “However, for an RN, patient care always includes the nursing process: assessment, diagnosis, planning, implementation, and evaluation.”

For the registered nurse, this process is part of every new patient encounter, situation, or challenge, said Graves.

Tasks that are common in nursing practice include:

• Taking vital signs
• Administering medications, IV fluids, IV medications, and blood and blood products
• Performing cardio-pulmonary resuscitation
• Suctioning airways
• Helping patients with ambulation, nutrition, and toileting
• Observing patients and recording those observations
• Consulting with doctors and other healthcare professionals
• Assisting with diagnostic tests and helping to analyze results

As you can see, nursing is a field that requires hands-on skills and critical thinking — and a knack for working as part of a larger team.

How Long Does It Take to Become an RN?

Becoming an RN can take anywhere from 18 months to four years, depending on whether you pursue an associate’s degree in nursing before taking the NCLEX or go for your bachelor’s degree in nursing. It also depends on whether you attend school part time or full time.

Like all career paths, becoming an RN has a required educational component. Nursing education generally includes courses in anatomy, physiology, microbiology psychology, and social and behavioral sciences.

Students applying to nursing school should make sure those schools meet quality standards with accreditation by one or more specific organizations. Accrediting organizations that set minimum standards for nursing programs include the Accreditation Commission for Education in Nursing (ACEN), the Commission on Collegiate Nursing Education (CCNE), and the Commission for Nursing Education and Accreditation (CNEA), according to The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity (FoN) report.

Students who want to become registered nurses have a few main degree options, which qualify graduates to take the NCLEX-RN.

The most common and generally recommended degree option is the Bachelor of Science in nursing (BSN). About 65% of the RN workforce are prepared at the baccalaureate level or higher, according to the NCSBN.

The BSN prepares nurses for the full scope of nursing responsibilities in the spectrum of healthcare settings, according to the FoN report. The report also states that the degree generally takes four years to complete and offers courses that traditional two-year or three-year nursing degrees might not offer, such as training in physical and social sciences, leadership, research, and public health.

“Most registered nurses today enter practice with a baccalaureate degree offered by a four-year college or university or an associate’s degree offered by a community college,” according to the American Association of Colleges of Nursing (AACN) Nursing Fact Sheet.

The BSN is also the degree typically required for entry into many master’s degree programs in nursing.

“While a bachelor’s degree is typically required to earn an MSN, there are bridge programs when RNs who have earned an [associate’s degree in nursing] ADN can complete an MSN,” Graves said.

The ADN also clears the path for nursing students to become RNs. It generally takes two years to complete and is offered at community colleges and hospitals. However, ADNs from some hospital-based programs, called diploma degrees, often require three years of education.

The ADN does not cover the same broad number of topics covered by the BSN, but it does prepare nurses to practice within the legal scope of nursing in a variety of healthcare settings.