This article examines several factors a vocational expert must consider when assessing a nurse’s labor market access, placeability, and earning capacity. It outlines the requirements of nursing occupations and the changing labor market. It also evaluates alternative jobs that some nurses might be able to perform if limited to lighter work, using their education, experience, knowledge, skills, and abilities.

Nurses provide and coordinate patient care, educate patients and the public about health conditions, and work in various environments. They are critical to a functional healthcare system. As discussed in the American Nurses Association’s Scope and Standards of Practice,

Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in recognition of the connection of all humanity (p.1).

Education & Licensure

The term “Nurse” is often used interchangeably with registered nurse or “RN.” There are three paths to becoming a registered nurse: a 3-year diploma program usually offered in hospitals; a 2-year associate degree (ADN) commonly provided at community colleges; and a 4-year bachelor’s degree (BSN) available at senior colleges and universities. Some also offer accelerated study programs (Wakefield et al., 2021).

Graduates from all three programs take the same National Council of State Boards of Nursing’s National Council Licensure Examination (NCLEX-RN® exam). This exam assesses their ability to use critical thinking skills to make nursing judgments and become licensed in their state. However, even with the same license, nurses holding a BSN may have more opportunities than those with less education. Some states, hospitals, and federal agencies indicate a preference or requirement for their nurses to hold a BSN. For example, New York State requires a BSN within ten years of initial licensure for new RNs (Article 139, Nursing for Registered Professional Nursing). Wakefield et al. and the American Association of Colleges of Nursing (AACN) also discuss increased educational requirements for registered nurses.

The educational level of the RN workforce has increased over time. Data from the National Nursing Workforce Survey, the largest national survey of the U.S. nursing workforce, conducted every two years, highlights this trend. From 2015 to 2024, the percentage of RNs reporting a BSN as their initial license rose from 39% to 46%, while those trained in RN diploma programs and ADN-prepared nurses declined by 5%, dropping to 9% and 34%, respectively. Most younger nurses in 2024 are educated at the bachelor’s level, with 77% aged 18-29 holding bachelor’s degrees, 2% holding diplomas, and 15% having an associate degree as their highest nursing qualification.

Nurses living in a “compact state” can apply for a multistate license if they meet the licensure requirements. The Nurse Licensure Compact (NLC) enables nurses to practice in other NLC states without additional licenses. Most U.S. states and territories are in the NLC (National Council of State Boards of Nursing).

Nursing occupations, such as Licensed Practical Nurses (LPNs) and Licensed Vocational Nurses (LVNs), require less education. These are considered technical, rather than professional, roles. They provide basic care, such as vital sign monitoring, medication administration, catheter monitoring, and dressing application, while working under the direct supervision of physicians and RNs.

In addition to direct patient care roles in various settings, other registered nursing roles include nurse practitioners, clinical nurse specialists, midwives, and nurse anesthetists. These roles require a current RN license as a prerequisite. They are referred to as advanced practice roles and require additional education and licensure. The roles of clinical nurse leaders, educators, and administrators require an RN license and may also require advanced degrees. This article focuses on registered nurses in direct patient care roles, which may be referred to as general duty or private duty roles.

Employment

The U.S. Department of Health & Human Services reports over 4.3 million registered nurses in the United States. Nursing is primarily female, but the percentage of male nurses has risen from 8% to 10.4% since 2015, according to the 2024 National Nursing Workforce Survey. The median annual wage for registered nurses was $93,600 in May 2024. Registered nurse employment has grown from 2,986,500 to 3,282,010 since 2020. Job opportunities are projected to increase by 6% between 2023 and 2033, outpacing the average for all occupations. Most registered nurses, 58%, work in hospitals. Others are employed in physicians’ offices, home healthcare services, nursing homes, outpatient clinics, and schools (U.S. Department of Labor, U.S. Bureau of Labor Statistics’ Employment Projections).

Cognitive Requirements and Temperaments

Nursing is a skilled profession, as registered nurses must complete extensive education and training and obtain licensure. General duty nurses (working in hospitals, nursing homes, or similar health care facilities) and private duty nurses (usually providing care to one patient in hospitals or private homes) are classified by the U.S. Department of Labor’s Dictionary of Occupational Titles (DOT) as having an SVP (specific vocational preparation) of seven (7). It takes two to four years to learn the techniques, acquire the necessary information, and develop the proficiency for average performance.

A nurse’s job requires strong reasoning, mathematical, and language skills. Nurses must perform well under stress and effectively manage people in emergencies and complex interpersonal situations. They are required to meet precise limits, tolerances, and standards by preparing accurate verbal and numerical records. They must also follow specific techniques and procedures and make judgments and decisions by critically assessing and solving problems (U.S. Department of Labor, 1991).

Physical Requirements

The nursing occupation typically has significant physical demands. The DOT classifies jobs according to various exertional levels, which describe the physical demands of different occupations. These classifications primarily depend on the strength needs of a job and include actions such as sitting, standing, walking, lifting, carrying, pushing, and pulling. The general and private duty nurse occupations are considered “medium” work. This means they are generally required to lift, carry, push, and pull up to 50 pounds occasionally, up to 25 pounds frequently, and/or up to 10 pounds constantly.

The U.S. Bureau of Labor Statistics has been collecting and publishing information about specific work-related requirements, including education, cognitive and physical demands, and environmental conditions as part of the Occupational Requirements Survey (ORS). The preliminary data indicate that most registered nurses report performing physical tasks consistent with medium work.

However, this may not fully cover the entire scope of a registered nurse’s responsibilities, which include walking, bending, stretching, standing, and lifting or moving patients during long shifts. Nurses are also typically required to be certified in cardiopulmonary resuscitation (CPR). This involves exerting up to 125 pounds of force for “high-quality compressions,” as defined by the American Heart Association (Geddes et al., 2007).

Chronic Pain and Other Considerations

The vocational expert must consider an RN’s limitations in performing any of the aforementioned physical tasks. They may also need to evaluate their nonexertional limitations. The Social Security Administration (SSA) discusses these in Section 404.1569 of the Code of Federal Regulations (CFR), noting that impairments and related symptoms, such as pain, may cause limitations in function or restrictions that limit a person’s ability to meet the specific demands of a job. These limitations may be exertional, nonexertional, or both. The CFR describes nonexertional limitations as difficulty functioning due to nervousness, anxiety, or depression; difficulty maintaining attention or concentrating; difficulty understanding or remembering detailed instructions; difficulty seeing or hearing; difficulty tolerating features of specific work environments, such as dust or fumes; and difficulty performing manipulative or postural functions such as reaching, handling, stooping, climbing, crawling, or crouching.

For example, nurses must frequently perform nonexertional tasks such as reaching, handling, and fingering. They must also occasionally need to stoop and frequently talk and hear (U.S. Department of Labor, 1993). A nurse with a limitation or work restriction in performing these activities may require a job modification or accommodation, even if they have no lifting or other exertional restrictions.

Another factor to consider is the presence of chronic pain, which is described as persistent pain lasting longer than three months or beyond normal healing time. Issa et al. (2012) discuss how some people with chronic pain may experience disruptions at work or even lose their jobs, and that employment can sometimes be difficult. For example, studies found that they missed three times more days than people without pain. Some individuals also experience “presenteeism,” where they are at work but not operating at “full capacity” (Adams & Salomons, 2021). Even when complete relief or cure is not possible, efforts can mitigate its effects and improve function, empowering individuals to develop coping skills, adopt lifestyle changes, and utilize medical treatments to maintain an effective and efficient lifestyle (Jayne, 2020).

The vocational expert must rely on medical opinions to evaluate the individual’s functioning level and work restrictions. Consulting with physicians and other medical professionals is often necessary because medical records frequently lack detailed information. When speaking with them, the expert asks questions, but they are more than just a scribe. These conversations require the experts’ comprehensive knowledge and strong communication skills. Sometimes, a tactful explanation of the occupation’s duties and the individual’s complete treatment history, which the medical professional may inadvertently overlook or be unaware of, is also necessary. Thoughtful questions can sometimes lead to more comprehensive medical opinions.

Importance of Work

A nurse with limitations may be unable to perform the essential functional demands of their job. Medical restrictions and limitations provide a framework for the expert to identify and consider the vocational implications of disability. The certified rehabilitation counselor’s key role is to empower people with alternative vocational options.

The Commission on Rehabilitation Counselor Certification website states that the purpose of the certified rehabilitation counselor is to “serve individuals with disabilities across a wide range of disabling conditions” and help them work toward “a self-sufficient, fully integrated life” by “focusing on the assets of the person.”

Szymanski & Hershenson (2005) discuss how work is central to people’s lives. In addition to providing economic support, an occupation reflects a person’s social status and self-concept and has psychological, interpersonal, and cultural meaning. Work also gives meaning and structure to adulthood, channeling the individual’s talents, abilities, and knowledge. Rehabilitation counselors are essential to addressing the employment problems of people with disabilities. They must evaluate potential accommodations, job modifications, or job changes to determine the best approach.

Accommodating the Injured Nurse and the Role of the Rehabilitation Counselor

The Job Accommodation Network (JAN) provides free, expert, and confidential guidance on job accommodations and disability employment issues. It discusses solutions specific to nurses, such as transfer aids, height-adjustable examination tables, one-handed syringes, modified keyboards, speech recognition software, phone applications, and other systems to assist memory, focus, or time management difficulties that could help them obtain and maintain employment.

While accommodations and technology can be helpful, these solutions do not work in every job environment or for every nurse. Bishop et al. (2024) discuss another critical aspect to consider is the individual’s psychosocial adjustment and capacity to cope with a disability. Disability adjustment counseling (DAC) is “focused on adjustment issues related to being diagnosed with and adapting to living with a disability or chronic illness” (p.3), and offers solutions. DAC can help in several areas, including understanding one’s condition, career assessment, maintenance or transition, self-advocacy, grief or loss, and accommodation. A certified rehabilitation counselor (CRC) can provide this service to help individuals adapt to changes in their functional capacity and any psychological, social, identity, and physical barriers. Local public vocational rehabilitation counselors often provide these, but some individuals may require private, one-on-one support services.

Stewart et al. (2021) discuss that non-exertional limitations, such as chronic pain, attention and concentration issues, and the side effects of prescription medications, can be risk areas for vocational experts. Experts must avoid making medical judgments and seek appropriate guidance from clinical professionals for functional limitations as outlined above. They also need to translate their findings into vocationally relevant terms. The authors highlight the importance of using a peer-reviewed, published methodology, such as the Transferability of Skills Analysis (TSA).

Transferable Skills and the Vocational Expert

“Transferable skills” are “skills that can be used in other jobs.” This SSA definition and the TSA are commonly used in Social Security disability determinations and other settings. The TSA provides a scientific method to evaluate the individual’s previous employment and how the skills used would translate to different jobs within their functional capacity. Havranek et al. (2005) discuss the Vocational Diagnosis and Assessment of Residual Employability (VDARE) process as a key method in vocational assessments. This, along with the software developed by SkillTRAN, LLC, is often used to analyze an individual’s transferable skills. These tools rely on the DOT and RHAJ to examine the occupation’s SVP (the amount of training and experience required for the job), Work Fields (the job purpose and how it is completed), and MPSMS (materials, products, subject matter, and services used to perform the job).

The general duty and private duty nurse occupations have specific job duties and DOT codes, but they fall under the same Standard Occupational Classification (SOC) group. The MPSMS for this group is “nursing, dietetic, and therapeutic services,” and the work fields are “health caring-medical.” It is essential to note that the Nurse Supervisor DOT job title is also within the same SOC group, despite its distinct job duties. These jobs are typically light in their exertional demands and require skills in analyzing, authorizing, contracting, coordinating, formulating, hiring, negotiating, planning, and scheduling.

Vocational experts should be aware that the job tasks the nurse actually performed might differ from the DOT description. A thorough clinical assessment could provide additional or conflicting information that needs to be considered. Data from vocational testing, other assessments, medical evaluations, and employment records may also influence the analysis.

If an RN were restricted to light work, they may be able to utilize their transferable skills to perform some roles, such as an office or school nurse, or a similar position. However, this change may reduce their labor market access, placeability, or earning capacity depending on their specific characteristics and the local labor market. Some individuals may transition into a supervisory or administrative role if they possess sufficient experience and education. Many of these jobs require a bachelor’s degree, and some prefer a master’s degree.

If a nurse were limited to sedentary or remote work, utilization management, telehealth, or triage nurse positions may be appropriate options. Labor market research revealed several job opportunities, but some remote positions require a bachelor’s or master’s degree in nursing; others demand working third-shift hours, weekends, or 12-hour shifts. Diabetes educator, health coordinator, or similar position are other potential job titles; however, depending on the location, these may be part-time, require significant travel, or require additional education and training.

Some nurses have the potential to work as legal nurse consultants. They review and summarize medical records to create detailed timelines for mediation and litigation, identify when additional documents or information are needed, conduct research, and sometimes testify. This work requires strong writing skills, attention to detail, and efficiency. This may also require substantial vocational adaptation for most nurses. A certification, such as the American Legal Nurse Consultant Certification Board’s Legal Nurse Consultant, may be suitable for a nurse interested in this work.

Additional certifications, like the American Holistic Nurses Credentialing Corporation’s Nurse Coach, the Commission for Case Manager Certification’s Certified Case Manager, and the Commission for Forensic Nursing Certification’s Sexual Assault Nurse Examiner (for adults or children), could enhance a nurse’s labor market access and placeability.

Another option is to become a certified life care planner (CLCP) through the International Commission on Health Care Certification or a nurse life care planner (CNLCP) via the Universal Life Care Planner Certification Board. Nurses with the requisite field experience must complete 120 hours of specialized life care planning training, submit a sample life care plan for peer review, and pass the examination. After certification, life care planners usually need extensive experience, training, and mentorship to succeed.

The nurse’s experience, education, specific job duties, work environment, and other factors, such as pre-morbid conditions, specific limitations and restrictions, functioning, family demands, and labor market conditions, should be considered. For example, most states participate in the NLC, allowing nurses to work in other labor markets without needing additional licenses; however, California does not. A nurse working in California who needs to work remotely could lose labor market access and placeability to some, if not most, jobs.

Conclusion

Nursing is challenging, typically requiring high stamina and physical strength, excellent interpersonal skills, and strong reasoning, mathematical, and language skills. When assessing a nurse’s access to the labor market and earning potential, the vocational expert must consider the individual’s exertional and non-exertional limitations, as well as other factors, including their education and experience.

Accommodations, technology, and job modifications may enable an RN to continue performing the same job. Lighter alternative jobs also exist that some nurses could perform, given their individual-specific characteristics. Disability adjustment counseling and vocational rehabilitation are often indicated to help nurses adapt to alternative work. Additional education, training, or certification may also be required.

The expert must conduct a thorough analysis of records, consult with medical professionals, consider accommodations, research the local labor market, and rely on a peer-reviewed, published methodology, such as the TSA, to perform a reliable evaluation of a nurse’s access to the labor market and earning capacity.