"Nursing is a dynamic discipline, which includes the assessing, caring, counseling, teaching, referring and implementing of prescribed treatment in the maintenance of health, prevention and management of illness, injury, disability or in the achievement of a dignified death."
N.C. Board of Nursing's Nursing Practice Act

“Dynamic” is an apt description of the nursing profession today. Like other areas of health care, nursing is constantly evolving, becoming more professional, highly skilled and specialized to fit the needs of patients in the 21st century. Nurses themselves are also dynamic, often starting out in one area of the profession and then gaining the skills and education to move to a more advanced level.

“One of the things I like about nursing as a career is there is a bridge in this profession like none other,” says Elizabeth Manley, R.N., C.S., a therapist with FirstHealth Behavioral Services. “You can start out with your certification as a nursing assistant. You can get your LPN. You can go on and get an R.N. You can get your associate’s degree, you can get your bachelor’s, you can get your master’s, and you can get your doctorate. So you can go all the way across that bridge.”

Donna Wright, a certified nurse midwife, took that route across the bridge from beginning to end, starting out as a nursing
assistant in a nursing home. “Then I got my LPN license, then my R.N.,” she says. “I got my associate’s, my bachelor’s and then my master’s. I took the long way around.”

Today, Wright is nurse midwife with Richmond OB/GYN. As she evolved in her career, she also was an observer of the evolution of nursing itself. “When I first started nursing, I had to clean instruments, clean the rooms, answer the phone, put charts together—everything,” she says. “You don’t see that anymore.

“Because of technology and so many more advances, each discipline has to be more specialized. You can’t know everything,
so it’s really important to be specialized in a particular area.”

So who are these specialized health care professionals who provide care in hospitals, physicians’ offices and in offices of their own? Here’s how to discern the difference in who is treating you.

Nursing assistants
Nursing assistants work under the direction of registered nurses and licensed practical nurses to perform nursing care activities such as obtaining vital signs, checking blood glucose and assisting patients with personal care. “We care for the patients and all of their needs and wants, and try to make them feel like they are at home and not just in a hospital facility,” says Bridgett Deason, a nursing assistant in the 46-bed Medical/Surgical Unit at FirstHealth Richmond Memorial Hospital.

Nursing assistants are not licensed; they have the ability to practice after completing a Nurse Aide Program certified by the N.C. Board of Nursing. “I had to have a high school diploma or GED and a six-week nurse’s aide course,” Deason says.

For many, the nursing assistant role is the first step on that nursing bridge. Once they take that first step, many decide to stay. “I wanted to get in the medical field so I could help people who were in need,” Deason says, “and to feel like I was giving something back to the community.”

Licensed practical nurses
LPNs are licensed nurses who care for patients in collaboration with or under the supervision of a registered nurse or a physician. These nurses must complete an LPN program certified by the N.C. Board of Nursing. The programs are usually one year in duration. “My interest in nursing came from my sister who is also a nurse,” says Kathy Cordial, LPN, with FirstHealth Moore Regional Convenient Care. “I was in awe when she talked about her day.”

Cordial began working as a nursing assistant at Scotland Memorial Hospital in Laurinburg. “Richmond Community College offered the LPN nursing classes on the hospital campus,” she says. “This allowed me to complete my day as a student, dress for work and begin my shift as an employee.”

Cordial says continuing her career as an LPN has afforded her many opportunities and experiences. The majority of her nursing career has been in the Emergency Department, but she has worked in everything from Obstetrics to Orthopaedics, Cardiology to Case Management.

“Nursing allows me to learn something new every day,” she says. “To care enough to make a difference in someone’s life and then be able to accomplish that—through doctors’ orders, treatment plans, working in conjunction with other staff or even just plain listening—gives the warm satisfaction needed when dedicating a lifetime.”

Cordial says her ultimate nursing accomplishment has been her recent election to a three-year term on the N.C. Board of Nursing. The 14 members include three LPNs, eight registered nurses and three appointed public members. “The vast degrees of education and experience of the members, along with the strengths and talents—30-plus years later I remain in awe,” she says.

Registered nurses
When most people think of nurses, the image of the R.N. comes to mind. These are the licensed caregivers who are accountable for the quality of nursing care given to patients, as well as the assignment of nursing responsibilities to LPNs and nursing assistants, says Bonnie Entwistle, R.N., director of the Medical/Surgical Unit at Richmond Memorial Hospital.

There are three educational routes that a person can take to become an R.N. After completing one of the three following programs, graduates are eligible to take the licensing exam to practice.

• Associate degree programs are the most common type of program and are offered through community colleges. The two-year program combines classroom and clinical education with the focus on “hands-on” clinical nursing. “I completed this program at Richmond Community College,” Entwistle says. “This type of program can also serve as a bridge to a four-year degree, allowing the nurse the ability to practice as an R.N. while pursing a baccalaureate degree.”
• Baccalaureate degree programs combine nursing courses with general education courses in a four-year program at a university. Many universities offer R.N.-to-BSN programs via Internet or once-a-week classes tailored for the associate degree nurse. “I am currently in an R.N.-to-BSN program at UNC-Greensboro,” Entwistle says.
• Hospital-based diploma programs were the earliest form of nursing education in the country. These are three-year programs with the courses taught at the hospital. Like the associate degree programs, there is a focus on hands-on nursing education and clinical skills. “With the gaining popularity of the associate degree programs, the diploma programs have dwindled in recent years,” Entwistle says.

Entwistle was 32 years old and the mother of three children when she decided to start nursing school for very personal reasons. “My third child (now 15 years old) was born 10 weeks prematurely after a seven-week hospital stay confining me to bed,” she says. “After finally getting him home, he suffered respiratory arrest at the age of 8 weeks, and I had to perform CPR on him. That was a life-changing experience, and that’s the reason I’m a nurse.”

When she entered Richmond Community College, Entwistle planned on becoming a labor and delivery nurse. “That changed when I got to the critical care component of training—it was a like a light came on,” she says.

She started her nursing career in the Medical/Surgical Care Unit at Richmond Memorial and then after a year transferred to the Intensive Care Unit, where she became director in 1999. “I really missed the hands-on experience,” she says, “so when an opportunity arose to work with FirstHealth Critical Care Transport, I took it.”

After three years, she returned to Richmond Memorial’s Medical/Surgical Unit as its director.

“The whole job is a challenge,” Entwistle says. “That’s one of the things I love about it. Making sure each and every patient on the unit receives the best care possible involves a lot of planning, coordinating and making sure the staff is educated, trained and prepared to care for them, and that they have the proper resources to do it.”

Advanced practice nursing
Advanced practice nursing allows registered nurses to specialize in several areas, in ways similar to physicians, according to DeAnna McCall, nurse recruiter for FirstHealth’s Human Resources department. There are four advanced practice nurse categories: clinical specialists, nurse practitioners, nurse midwives and nurse anesthetists.

“All advance practice nurses (APRNs) must be licensed as an R.N., have advance training beyond the two to four years required of R.N.s and have national certification,” McCall says.

Typically, APRNs also have a master’s and/or doctorate in their field.

“When R.N.’s pursue specialized areas of nursing—either at the advanced practice level or as an R.N. obtaining national certification in a particular area—we raise the level of care for the patient,” McCall says. “It also affords nurses the opportunity to pursue areas of patient care in which they have strong skill sets or a particular enthusiasm for.”

Clinical specialists are APRNs both within and outside the hospital setting, says Manley. “The clinical specialist role (C.S.) grew out of the need for expert nurses in the hospital to work with patients at an advanced level and to train and supervise nurses in their clinical level,” she says. “For example, a C.S. in cardiology would do patient assessment, patient teaching, clinical supervision and clinical planning.”

Clinical specialists in the psychiatric field have a unique role, according to Manley. “Around the 1960s, psych clinical specialists who had developed a lot of expertise and skill in the inpatient setting started moving out into the private practice setting, which is not necessarily paralleled in other specialties,” she says. “Psych clinical specialists put out their shingles even before there were nurse practitioners.”

The psych C.S. is autonomous and is not supervised by a doctor. “You have to maintain your C.S. certification every four years,” Manley says. “You either have to take the test again or present evidence of a certain number of continuing education units.”

Manley says that nursing is a very good match with psychotherapy, which includes other caregivers such as psychologists and therapists with master’s degrees in social work, because nurses are trained more holistically.

“I understand the physiological aspects of what is going on with the patient,” she says. “For example, if someone comes to me depressed, I know that they need things ruled out such as whether their thyroid is functioning correctly and what kind of medications they are on. I will talk to somebody about stress and how it affects their whole body, mind and spirit, and address the stress at all those levels. I will talk to them about how exercise is the best antidepressant there is, and I’m going to talk with them about their weight and how that affects them. I talk about all of that stuff, because I’m a nurse and I see the whole person.”

Nurse practitioners are a type of primary care provider who practice in acute settings such as hospitals and ambulatory care settings such as physician offices, as well as long-term-care settings. Nurse practitioners can diagnose and manage both acute and chronic illness; order, conduct and interpret tests; and prescribe medications and other treatments. They also emphasize health promotion and disease prevention.

“Specialization in nursing is good, but you need the generalists who can put the whole picture together, and primary care nurse practitioners are really good at that,” Manley says. “And they are notorious for spending more time with the patient.”

Cheryl Rachels, FNP, is a family nurse practitioner with the office of Thomas Lineberger, M.D., in Aberdeen. “I was an R.N. working in an outpatient and ER setting for two years,” she says. “The nurse practitioner role was just evolving, and I decided that was the path I would pursue.”

After focusing on the FNP role, Rachels never changed her mind and has worked in that realm since 1976. Being a nurse practitioner fulfills the need that some nurses have to form longer relationships with their patients.

“I have the best of both worlds,” Rachels says, “the nursing aspect and the ability to diagnose and treat medical conditions. I have enjoyed getting to know my patients over the years, and now I am seeing the children of some of these patients.”

Creating a longer relationship with patients was one of the reasons Wright became a nurse midwife. “I was a traveling labor and delivery nurse, an R.N. with an associate’s degree,” she recalls. “And I thought, ‘Well, I can deliver a baby.’” The difference between what I was doing as a labor and delivery nurse and what I am doing now is I am administering prenatal care for patients. I see them from the very beginning of their pregnancy to the very end. That’s what I was missing when I did labor and delivery.”

While working as a traveling nurse, Wright attended San Jose State in California to receive her bachelor’s degree. Once she decided she wanted to go into midwifery, she attended the Frontier School of Midwifery and Nursing in Kentucky to receive a two-year degree for midwifery and then obtained her master’s degree through Case Western University in Ohio.

“Nurse midwives are independent practitioners,” says Wright. “We can have our own practice to take care of obstetrical patients. We can do normal vaginal deliveries; anything beyond normal, we have to have an arrangement with an obstetrician. We can also do gynecological care, and some nurse midwives do newborn exams on babies after they are delivered.”

Being a nurse midwife allows Wright to take a more holistic approach to childbirth. “Midwifery prefers to let nature take its course rather than managing labor,” she says. “Nursing has a tendency to look at the patient more as a whole. And I like the idea of trying to treat every aspect of the patient instead of just one.”

Advanced practice nursing
Despite the changes related to nursing specialization, the basic commitment to patient care has been a constant for the profession throughout the generations. That seems to be true despite the area of specialization—be it midwifery, emergency medicine or intensive care.

“In some ways, nursing has changed dramatically over the past several decades, and in some ways it hasn’t,” says McCall. “Technology has required nurses to be technologically savvy, a relatively recent development. However, since the time of Florence Nightingale, nurses have been focused on providing compassionate care for people in need, and that has not changed.”