The registered nurse licence is the centre of the American nursing structure. Everything above it is built on it — the four advanced practice roles all require it first — and everything below it is defined by delegation from it. About 3,465,400 people held registered nurse jobs in 2025, with a median wage of roughly $97,550 a year, or $46.90 an hour.
What the licence actually authorizes
Practice acts differ in wording, but the authority is consistent in substance. The registered nurse may assess a patient, reach a nursing diagnosis, plan and carry out nursing care, evaluate the patient's response, teach the patient, administer treatments and medications ordered by an authorized prescriber, and delegate tasks to others while retaining accountability for the outcome.
Two of those matter more than the rest. The first is assessment, because it is the act that separates this licence from the practical nurse's and is the reason a registered nurse cannot hand it to anyone else. The second is delegation, because it is the point where the licence is most often lost — not through doing something wrong personally, but through failing to supervise something handed to someone else. See scope of practice, the nursing process, and nurse practice acts and boards of nursing.
What the licence does not authorize is medical diagnosis or independent prescribing. Those require the advanced practice tier and, in many states, a formal relationship with a physician. See nurse practitioner practice authority.
Three routes, one examination
A hospital diploma, a two-year associate degree, and a four-year bachelor's degree all lead to the same licence and the same examination. That has been contested inside the profession since 1965, and the argument has been settled by employers rather than by legislators: no state requires the bachelor's degree for licensure, but federal occupational data now lists it as the typical entry-level education, and many large systems and Magnet-recognized hospitals hire almost exclusively at that level or require completion within a set period after hire. See entry into practice and the BSN requirement and Magnet recognition.
Two other routes matter in volume. Accelerated bachelor's programmes take people who already hold a degree in something else and produce a nurse in roughly 12 to 18 months, and they are a significant source of second-career entrants. Bridge programmes move practical nurses into associate degree programmes with advanced standing.
Whatever the route, the graduate sits the registered nurse licensing examination. See the NCLEX.
Getting and keeping the licence
Licensure is a state act. A first licence is granted by examination; a nurse already licensed elsewhere is granted one by endorsement, a paper process that in some states takes weeks and in others months. See licensure by endorsement.
The nurse licensure compact changes this for the states that have joined it: a nurse whose primary residence is in a compact state may hold one multistate licence and practise in the others without applying separately. That single fact underpins the economics of travel nursing and of telephone and telehealth work across state lines.
Renewal is periodic, usually every two years, and most states attach continuing education requirements — often with mandated topics such as pain management, human trafficking recognition, implicit bias, or state law. Nurses educated outside the United States face a longer route through credential evaluation, English testing, and a visa screen. See internationally educated nurses.
Where registered nurses work
Hospitals employ about 59 percent, which is a smaller share than the profession's self-image assumes and has been drifting downward. Ambulatory healthcare services — physician offices, outpatient centres, surgical centres, home health agencies, dialysis clinics — employ about 19 percent. Nursing and residential care facilities take roughly 6 percent, government about 5 percent, and educational services about 3 percent.
Inside the hospital the work divides by unit, and each unit is a distinct practice with its own knowledge base, staffing ratio, patient population, and often its own certification. See nursing specialties.
The staffing question sits underneath all of it. How many patients one registered nurse is responsible for is the single most studied variable in nursing services research and the one most fought over in legislatures and at the bargaining table. See nurse staffing and patient outcomes, patient acuity and staffing systems, and nurse strikes and bargaining.
The shape of the workforce
Employment is projected to grow about 6 percent through 2035, faster than the average across occupations. The more revealing figure is openings: about 180,800 a year, most of them replacing nurses who retire or leave the occupation rather than filling newly created posts.
That is the arithmetic behind the shortage debate. The United States does not produce too few nursing graduates so much as it loses experienced nurses faster than it can season replacements, and the losses concentrate in the first years at the bedside. See the nursing shortage, nurse turnover and retention, nurse burnout, and nurse residency programs.
Where the careers go
Four directions are common, and they are genuinely different careers rather than steps on one ladder.
Deeper into a clinical specialty, usually marked by a certification. Certification is voluntary and does not widen scope, but it is a hiring signal, sometimes carries a differential, and is counted as a structural quality measure at unit level.
Into advanced practice — nurse practitioner, nurse anesthetist, nurse-midwife, or clinical nurse specialist — which requires graduate education, national certification, and a second licence or recognition from the board.
Into management, from charge nurse through unit manager, director, and chief nursing officer. This is a business role that people arrive at from clinical work with little preparation for it, which is why the transition fails as often as it does.
Out of direct care into informatics, quality, infection prevention, case management, utilization review, education, research, legal nurse consulting, or industry. These pay variably and are the destination for a large share of nurses who leave the bedside without leaving nursing.
Related
- Levels of nursing
- Nurse practitioners
- Registered nurse pay
- Nursing specialties
- Scope of practice
- The NCLEX
Sources
- Occupational Outlook Handbook: Registered Nurses — U.S. Bureau of Labor Statistics, 2025 data. Accessed September 9, 2026.
- Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education — APRN Consensus Work Group and NCSBN APRN Advisory Committee, July 7, 2008. Accessed September 9, 2026.
- National Guidelines for Nursing Delegation — National Council of State Boards of Nursing and American Nurses Association, 2019. Accessed September 9, 2026.
- Nurse Licensure Compact — National Council of State Boards of Nursing. Accessed September 9, 2026.