Steps to Choosing a Nursing Specialization

Steps to Choosing a Nursing Specialization

Many nurses, once comfortable with the day-to-day practice of nursing, decide that the next natural step is to go the specialization route. The thinking is that nurses who select a specialty will enjoy a higher salary, greater employment demand, and career-long job security than those who don’t. The US Bureau of Labor Statistics reports that registered nurses earn a mean wage of $68,910 annually, while nurse midwives earn $92,230; nurse practitioners earn $95,070; and nurse anesthetists earn $157,690. Not all specialties guarantee increased earnings—a parish nurse, say, is typically unpaid—but the niches that demand additional training, certification, and experience that’s in short supply almost always do.

However, not everyone agrees that specialization is the best approach to navigating a nursing career. “Some nurses start out interested in pediatrics, ER, or labor and delivery, but most don’t,” says Donna Cardillo, RN, MA, a nursing career coach ( “Many nurses feel pressured to choose a specialty and feel deficient in some way if they don’t. That’s an old, outdated model. Most of us used to work in one specialty our whole career. It’s not like that anymore. We’re going to work in many different specialties and work settings. It’s common to weave in and out of specialties all the time.”

Cardillo believes the health care landscape has changed and so has the job market. Jobs are moving out of hospitals to alternate inpatient settings—long-term care, inpatient rehab, subacute care, and long-term subacute care.

“New nurses have to think more about the opportunity itself—the support they will get and the opportunity to grow personally and professionally, rather than ‘choosing a specialty,’” says Cardillo. “But they also have to think about opportunities outside of the hospital. For example, if interested in pediatrics, consider pedi long-term care, pedi home care, [or] pedi rehab.”

Regardless of whether you pursue a specialty or a good opportunity, as Cardillo advises, it turns out that the steps are very similar. It means thoughtful consideration, energetic career exploration, and possibly pursuing more education, certification, and on-the-job training. Here are three simple steps to specialization, plus the career stories of three nurses in some of today’s most popular specialties.

Look Inside

One of the best online resources for nurses considering a specialty is at, which is sponsored by Johnson & Johnson. They offer a comprehensive Find Your Specialty quiz that starts with your education and skills (current or projected), then goes on to your favorite work roles and preferred work environment. Here are some representative questions and possible answers, slightly modified for brevity:

Q: What are you good at? 

A: Tech savvy; good communicator; strong leader; compassionate; calm

Q: When it comes to your patients, the best way you can help them is:

A: Face-to-face; managing, training, or teaching nurses; doing research, writing, or advocating

Q: When mingling with colleagues, how do you join the conversation?

A: I lead it; I usually listen at first; I listen

Q: At work the perfect pace for you is:

A: Slower; steady; faster

Q: Your ideal day at work is:

A: Pretty much the same; slightly switched up; completely different

At the end of the test, you’ll get a top recommendation for a specialty, plus two alternatives. Each one is described in detail and includes a list of advanced training, educational degrees, or certifications required to practice. Finally, there’s a profile of a successful nurse in that specialty to give you a sense of what’s required to find satisfaction on that career path.

Look Outside

After self-exploration, it’s time to do some workplace exploration. Nurses get a great deal of first-hand knowledge of various categories of nursing as they do their rotations during nursing school. If you pay careful attention to your “gut level” reactions—to medical-surgical, pediatrics, obstetrics, or critical care—you will discover which specialties appeal to you at a deeper level. You may want to explore additional specialties through internships, externships, temporary assignments, or PRN work outside your regular work duties.

If an actual, in-the-field trial is not an option, consider going online to learn about other categories. At, there is a database of 104 nursing specialties that you can access in a variety of ways. The specialties cover the gamut, so there’s something for everyone: 34 are outside hospital settings, 68 are research connected, 37 are managerial, and 92 are patient-facing.

One of the best parts of this database is that you can filter it by health care setting, degrees/certifications required, and job characteristics, so you don’t have to wade through all 104 specialties. The site will “curate” the ones that match your specific requirements.

One of the key factors that nurses consider when choosing a specialty is employment demand. Many associations survey their members about employment and publish results. Say that you’d like to be an OR nurse and know that the Association of periOperative Registered Nurses (AORN – online at reports that the average age of their members skews high, plus a quarter of OR nurses plan to retire or work part-time in the near future. Those demographic factors may increase job demand—or not. You have to dig a bit deeper to find out.

Now that you’ve chosen a few specialties to explore, it’s time to get out there and do some personal sleuthing. You can attend the professional association meetings near you, go to area conferences, or connect with RNs online at nursing specialty forums and at networking and social media sites.

So, when pursuing insights about being an OR nurse, for example, ask nurse leaders what prospective nurses should know about that specialty. Here’s what Deb Cooksey, RN, MBA, MS, CNOR, vice president of nursing at AORN notes: “First, they need to understand that their experience with the patient is very different; it’s very short and concise—probably the biggest difference they would experience. Also, working as part of a team is often a big change; many nurses are used to working autonomously. Another area where there is a significant difference is in how work is done; in Periop, it’s often multitasking but in a consecutive way. That can take getting used to.”

Next up, arrange one-to-one informational interviews with nurses who are successfully working in that specialty to find out more about their individual career path and what they’d suggest to a newcomer. Cardillo recommends asking experienced nurses these questions:

• How did you get started in this specialty?

• What do you like most and least about your specialty?

• What are the most important attributes of a nurse in this specialty?

• What trends do you see in this specialty?

“You’ll get your best information from those in the field, but take it with a grain of salt—that’s another reason why you should speak to four or five people,” Cardillo adds, so that nobody’s opinions weigh too heavily on your decision to pursue a specialty. Make a point to ask each person you interview for the names of one or two other nurses, and if they’re willing to make an introduction or let you say they referred you.

Assess Opportunities

Take a look at your overall career goals and areas of interest, the type of lifestyle you aspire to, your personality and work style, and the time and other resources required to pursue an avenue.

So, for instance, if you think you’d enjoy independent case management but you don’t have funds available to get a business off the ground (and wait for it to grow to support you), maybe that isn’t a good initial specialty.

Then, of course you’ll want to see what offers you get as a way of determining if your job target is actually viable. “Whether a new or experienced nurse, you don’t want to stay unemployed for any length of time,” says Cardillo. “You can continue to pursue your dream job while you’re working. Say you’re interested in pediatrics, but can’t get hired in a hospital on that unit. Maybe you get offered a job on a telemetry unit. You might consider taking that because it’s easier to get transferred into another unit than hired from outside.”

Below, three nurses weigh in on their journey to a specialty, with some advice for other nurses:

Lisa Pacheco
RN, BSN, Director of Maternal Child Services, Children’s Hospital at Nevada University Medical Center, Las Vegas

My personal journey

I always knew I wanted to help moms and babies, because of a nurse who took care of me when I had my older child. I went into nursing school with the idea of maternal care but was advised not to specialize early on so I did medical-surgical nursing, then neuro subacute nursing, then I made a full circle back to my passion, a women’s care unit, and realized my love of taking care of women and children. It’s a place where I can leave my footprint and make a difference. We’re a voice for families, making sure they’re taken care of.  I’ve been doing this for 23 years. There are so many aspects to this field—antepartum, NICU, women’s care unit, community nursing—it’s so broad so you can really find your niche.

Who does well in this specialty

Nurses with a passion for taking care of mothers and children do best. Follow your heart, and then even on that hardest day when you don’t think you can come back to work, you will. Find a unit that takes in new grads and trains them. Be careful not to take just anything. You want it to work for your goals.

What might surprise you about this specialty

A lot of nurses want to take care of moms and babies, but sometimes there’s disillusion. Having a baby is a dangerous thing. I always say it’s the most dangerous point of a young woman’s life. We triage patients, we have an OR for C-sections. If you work in a birthing center, it’s usually a quiet, beautiful experience. But if it’s high risk, like here at the hospital, you’ll have your fill of adrenaline. The NICU is different still, and so is postpartum.

Also, when I started, if you weren’t healthy you didn’t have babies. Now patients can have diabetes, heart problems, and asthma, and still get pregnant. Their health is compromised and their pregnancy is high risk. Patients come in by ambulance, very ill, and a lot of moms end up in the ICU later—with nothing that’s pregnancy related.

Downside of specialization

If you do specialize early, you may fear layoffs. If you’ve been a NICU nurse for 15 to 20 years, for instance, those nurses have a really hard time getting another job if we have a layoff.

For more information on this specialty, visit The Association of Women’s Health, Obstetric and Neonatal Nurses website at

Erik Meyer,
RN, BSN, Nursing Supervisor, Providence Seaside Hospital, Oregon

My personal journey

I chose ER for selfish reasons—I’m an instant gratification person. In the ER, either we fix them or we send them away. Instant results. We get a go at it, and if they stabilize they go to ICU or another department. When I was in nursing school, I saw a level 1 trauma center in inner-city Detroit. Everything you see on TV—well, that was that place. It was just a one-shift visit, but the next day I applied for a two-year internship. There were 500 applicants and they hired 30 of us. It was a free-for-all, fly-by-the-seat-of-your-pants kind of place, but a great place to learn.

I’ve been in the ER at a small, rural, critical access hospital for 18 years, now as a nursing supervisor. I work two 12-hour shifts; my wife and I are raising four kids and running a coffee business. That’s the great thing about nursing—you can work as much or as little as you want.

Who does well in this specialty

It’s so intense and we’re so busy that waiters and waitresses make the best ER nurses. You know to grab everything you need before leaving the kitchen, then check in on everyone to see how they’re doing and give them the best service possible! The ER is so like the food-service industry. That’s what I grew up doing—waiting tables.

Job search advice for new nurses

Just keep pushing. Introduce yourself to the ER manager and let them know your goal. Tell them, “If you need help, I’m available.” Keep pushing. When you pass them in the hall, ask “When can I work for you?”

ER personnel will respect people who are assertive. If you’re leaning in this direction, start getting your certifications in order and working towards becoming a Certified Emergency Nurse. Get the books and start studying for the test.

For more information on this specialty, visit the Emergency Nurses Association at

Brittney Wilson,
RN, BSN, also known as “The Nerdy Nurse,” Clinical Informatics Nurse, Georgia

My personal journey

After my second year of bedside nursing, I knew that I couldn’t do it forever. It’s backbreaking and emotionally draining. I began searching for MSN programs that would allow me to elevate my career and stumbled upon something called “Nursing Informatics.” When I read the job description, it was like the clouds parted, the sun broke through, the angels began to sing. Most informatics nurses are BSN-prepared. So I decided to pursue the career without the MSN in hand to see if I got any traction; three months later, I was hired. Of course, my technology savvy as conveyed through my blog ( were a big help with that. In my day job, I get to do what I love every day: combine technology and health care to improve patient outcomes.

Who does well in this specialty

One of the primary parts of my job is translating the needs of nurses to IT and the needs of IT to the nurses and other clinical staff. Sometimes, when nurses and nerds get together, it can seem like they’re speaking two separate languages. That’s where informatics nurses come in.

Job search advice for this specialty

Informatics nursing has become a hot specialty, and because of this, it can be really difficult to get your foot in the door. I will say that, at minimum, you should be BSN-prepared with at least three years of bedside nursing experience. The MSN credential will certainly be a help, but many organizations also want experience, so try to find some way to get IT or technical experience.

Certifications do command a higher salary. According to the HIMSS 2014 Nursing Informatics Workforce Survey, the average salary for an informatics nurse in 2014 is $100,717, while the average salary for a nurse who is certified in nursing informatics is $121,830.

For more information on this specialty, visit the American Nursing Informatics Association at

Career advice for any nurse

Read nursing blogs! There are many message boards that are filled with negativity and lots of complaining. If you want to find something more uplifting and connect with people who are really passionate about nursing, then nursing blogs are where it’s at!

Jebra Turner is a freelance health and business writer based in Portland, Oregon. She frequently contributes to the Minority Nurse magazine and website. Visit her online at 

Affirmative Action and College Admissions

Affirmative Action and College Admissions

Affirmative action has been a hot topic for decades. Since its tumultuous inception almost 50 years ago, affirmative action has been applauded, argued, and scoffed at as an answer to racial inequality.

In 1961, President John F. Kennedy was among the first to use the term “affirmative action” as a method to prevent further racial discrimination despite civil rights laws and, essentially, to temporarily level the playing field. Executive Order 10925 required that government contractors “take affirmative action to ensure that applicants are employed, and that employees are treated during employment, without regard to their race, creed, color, or national origin.”

But it was President Lyndon B. Johnson who developed and enforced it for the first time in 1965 with the passage of Executive Order 11246.

“This is the next and more profound stage of the battle for civil rights,” Johnson said to a Howard University graduating class in 1965. “We seek…not just equality as a right and a theory, but equality as a fact and as a result.”

Since then, the debate over affirmative action has grown more and more contentious and problematic as the public—with divided opinions—have weighed in on a complex issue.

Robert A. Schaeffer, the public education director of
FairTest, the National Center for
Fair & Open Testing, believes that many issues relating to race are highly controversial because critics have been able to define policies as “preferences” rather than “balancing” the playing field.

“Many Americans are convinced that affirmative action creates biases in favor of certain groups,” says Schaeffer. “Particularly in economic tough times, it is not difficult to fan resentment against any plan that seems to advantage [some] while disadvantaging others.”

Schuette v. Coalition to Defend Affirmative Action

In recent months, the battle over affirmative action once again gained momentum in light of the latest Supreme Court rulings. In April, the Supreme Court upheld a constitutional amendment Michigan voters approved in 2006, banning preferential treatment based on race, gender, ethnicity, or national origin in admissions to the state’s public universities.

By a vote of 6 to 2, the court concluded that it was not up to the judges to overturn the 2006 decision by Michigan voters to bar consideration of race when deciding who gets into the state’s universities and made it clear that states are free to prohibit the use of racial considerations in university admissions.

“This case is not about how the debate about racial preferences should be resolved. It is about who may resolve it,” Justice Anthony Kennedy wrote in an opinion joined by Chief Justice John Roberts and Justice Samuel Alito. “There is no authority in the Constitution of the United States or in this court’s precedents for the judiciary to set aside Michigan laws that commit this policy determination to the voters.”

Justice Sonia Sotomayor, on the other hand, blasted the majority, who she said attempts to “sit back and wish away” evidence that racial inequality exists.

“The stark reality is that race still matters,” Sotomayor wrote in her 58-page dissenting opinion joined only by Justice Ruth Bader Ginsburg. “The way to stop discrimination on the basis of race is to speak openly and candidly on the subject of race, and to apply the Constitution with eyes open to the unfortunate effects of centuries of racial discrimination.”

Moving Forward

It is unclear how the decision might move other states. Eight states, including Nebraska, Arizona, and Washington, now have bans on affirmative action. The ruling could encourage other states to join the handful that already have such prohibitions, such as California and Florida.

But what’s worrisome to proponents of affirmative action is the precedent that may have been set with the court’s ruling, potentially, further energizing opponents of racial preferences, who have already outlined plans to put Michigan-style constitutional amendments on the ballot in Utah, Ohio, and Missouri.

A survey conducted by ABC News and The Washington Post last year found that 79% of whites and 71% of non-whites oppose the consideration of race and ethnic preferences in college admissions, suggesting that any affirmative action ballot measures are likely to be voted down.

Moving forward, Roger Clegg, president and general counsel of the Center for Equal Opportunity believes that the court’s decision means that colleges in states that have banned racial preferences must follow those laws and other states without bans should reexamine with current plans.

“It also means that colleges in other states must take into account the fact that their continued use of racial preferences, which is unpopular, should consider getting rid of that policy since it may be banned in their states, too,” Clegg adds.

Quite the contrary, says Michael Olivas, director of the Institute for Higher Education Law and Governance at the University of Houston Law Center. “It hurt the choices that Michigan colleges wanted to make, and this violated their academic freedom.”

But it need not be a regressive process, Olivas continues. In Maryland, voters approved resident tuition for the undocumented in a ballot measure, and Colorado voters turned down a Michigan-type measure.

“They are neither good nor bad in and of themselves, except we should not make such important decisions for colleges by this means,” Olivas adds.

The groups that challenged the Michigan affirmative action ban pointed out the basic unfairness of giving preferences in admission to some groups while banning similar treatment of African Americans, Latinos, Native Americans, and women.

“Michigan higher education leaders and most major civil rights groups reinforced our arguments,” says Schaeffer, who provided expert assistance to the groups challenging Michigan’s ban. “However, the judicial system held that voters could impose whatever distinctions they determined to be reasonable.”

Impact on Minority Enrollment

What is not clear is the ruling’s impact on minority enrollment. While the US Supreme Court affirmed Michigan’s constitutional amendment banning race-conscious admissions, states that forbid affirmative action in higher education, like Florida and California, as well as Michigan, have seen a significant drop in the enrollment of black and Hispanic students.

In April 2014, The New York Times published an article examining how minorities have fared in states with affirmative action bans, including California, Florida, and Michigan. At UC Berkeley and UCLA in California, for example, the graphs showed that 49% of the state’s college-aged residents are Hispanic, though only 11% and 17% of freshmen are Hispanic at those two schools, respectively.

In Florida, 27% of the state’s college-aged residents are Hispanic at Florida State and the University of Florida, yet both universities showed that only 18% of their freshmen was Hispanic.

While the decision didn’t address the constitutionality of race-conscious admission policies, Justice Sotomayor cited student-demographic data as proof that the ban, which went into effect in December 2006, has adversely affected minority enrollment and diversity at the University of Michigan (UM) in Ann Arbor.

“A white graduate of a public Michigan university who wishes to pass his historical privilege on to his children may freely lobby the board of that university in favor of an expanded legacy admissions policy,” she wrote. “Whereas a black Michigander who was denied the opportunity to attend that very university cannot lobby the board in favor of a policy that might give his children a chance that he never had and that they might never have absent that policy.”

According to the policy brief, “Restructuring Higher Education Opportunity?: African American Degree Attainment after Michigan’s Ban on Affirmative Action,”  which Justice Sotomayor cited in her dissenting opinion, the proportion of African Americans who obtained a bachelor’s degree at UM dropped by about one-third after the ban on race-conscious admissions went into effect.

Additionally, The New York Times article revealed that the enrollment of black freshmen at UM between 2006 and 2011 dropped from 7% to 5%, despite the number of black college-aged persons in Michigan increasing from 16% to 19%.

While Justice Sotomayor argued that the ban on race-conscious admissions might have had a negative effect on the number of minority students who enrolled, it has not necessarily stopped colleges from looking at alternative procedures to maintain and promote diversity.

A 2012 study by The Century Foundation, a nonpartisan group, found that at seven of 10 major schools where racial preferences could not be used, race-neutral alternatives helped maintain or even raise minority representation.

For example, Texas’s Top Ten Percent Rule—which guarantees admission to the University of Texas (or any state-funded university) to any high school senior graduating in the top 10% of his or her class—helps ensure diverse college student bodies. A combination of measures, including affirmative action based on class, increasing financial grants, and de-emphasizing standardized tests are just a few promising race-neutral options that have allowed minority enrollment to return to pre-ban levels.

“From FairTest’s perspectives, all these initiatives are worthy of consideration,” says Schaeffer. “But none fully replace affirmative action as a tool for addressing past and present discrimination.”

Fisher vs. University of Texas at Austin

Last June, the justices had a chance to make another big statement on affirmative action with its decision in Fisher vs. University of Texas at Austin (UT Austin). The case was filed by Abigail Fisher, a young woman from Texas who applied to the university but was rejected. Fisher, who is white, then filed a lawsuit, arguing that she had been a victim of racial discrimination because minority students with less impressive credentials than hers had been admitted.

The Supreme Court did not immediately decide the fate of Fisher. Instead, the justices voted 7-1 to return the case to the lower courts to determine whether the use of race is “necessary” and have “the ultimate burden of demonstrating, before turning to racial classifications, that available, workable race-neutral alternatives do not suffice.”

“Strict scrutiny must not be strict in theory but feeble in fact,” Justice Kennedy wrote. “The reviewing court must ultimately be satisfied that no workable race-neutral alternatives would produce the educational benefits of diversity.”

Only Justice Ginsburg dissented in the decision to send the case back.

“I would not return this case for a second look,” Ginsburg wrote in her dissent. “The University reached the reasonable, good-faith judgment that supposedly race-neutral initiatives were insufficient to achieve, in appropriate measure, the educational benefits of student-body diversity.”

The ruling upheld Gratz v. Bollinger and Grutter v. Bollinger, two cases fundamental in defining universities’ rights to consider race as an admissions factor. Though many argue that the court’s decision preserves the principle that affirmative action is permissible in some circumstances. That, according to Olivas, depends upon the narrow tailoring that the remand requires.

“UT Austin is allowed to use race (by Grutter), and the top ten percent plan—which I helped write—is race-neutral, so Fisher was not harmed. She was simply not admissible,” Olivas argues. “The plan allows in over 50% whites, in a state where whites are only 30% of the [high school] population. It does not harm them, nor does the modest affirmative action policy.”

It can be said both decisions illustrate the court’s skepticism about race-conscious government programs. The Schuette v. Coalition to Defend Affirmative Action ruling alone took five separate opinions totaling 102 pages written over six months—a sign of how divided the court remains on the issue and the role the judiciary should play in protecting racial and ethnic minorities.

To most, the recent Supreme Court’s decision upholding Michigan’s affirmative action ban was far from a shock, but many believe the ruling could symbolize a steady march to the end of the use of race in higher education.

But, for now, the most recent Supreme Court decision only impacts public colleges and universities in the state of Michigan. The voter-approved Constitutional amendment clearly bars them from considering race, gender, ethnicity, or national origin in admissions and related decisions.

“For higher education institutions in other jurisdictions that are not operating under similar bans [some states, such as California, have their own prohibitions], affirmative action policies that comply with the court’s Hopwood [v. Texas] and Grutter decisions remain legally permissible,” says Schaeffer. “However, many who closely observe the Court believe that further restrictions on affirmative action are likely as the result of Fisher and other cases, currently moving through the judicial system.”

Terah Shelton Harris is a freelance writer based in Alabama.