family practice, or primary care. Their usual responsibilities include managing clinical care; they conduct physical examinations, track medical histories, make diagnoses, treat minor illnesses and injuries, and perform an array of counseling and educational tasks. Nurse practitioners may also, in some circumstances, order and interpret diagnosis tests and prescribe medications. Certified nurse midwives are RNs who have graduated from a nurse midwifery program accredited by the American College of Nurse-Midwives (ACNM) and are certified as a nurse-midwife by the ACNM; some may have taken a master's program offered by a school of nursing or a school of public health. They provide prenatal and gynecological care, deliver babies in a variety of settings (hospitals, birthing centers, or homes), and render postpartum care. Finally, certified RN anesthetists have a bachelor of science in nursing and 2 to 3 years of additional education and training in anesthesiology, often at the master's level. They, too, have a rigorous certification process, managed through programs approved by the American Association of Nurse Anesthetists. Particularly in rural areas, these nurse specialists may administer the majority of anesthesia or anesthetics in health care settings today.

Clearly, well-trained advanced practice nurses can function in a number of different roles. They can work independently to solve patient care problems, serve as patient advocates, and be integral members of a health care team. Advanced practice nurses can improve the cost-effectiveness of health care systems and facilities because changing the mix of personnel involved in caring for patients with complex management problems may yield better outcomes, lower costs, or both. The committee concludes that the way should be clearer for such personnel to be used in both inpatient and outpatient settings and for them to be able to take up leadership positions and act independently.

One obstacle, however, to accomplishing the changes advocated in this section lies in the differing ways in which states recognize advanced practice nurses, chiefly in terms of the breadth of independent authority (e.g., diagnosing, prescribing, and dispensing of medical therapeutic agents or controlled substances) (Pearson, 1995; Ray and Hardin, 1995). Some state boards of nursing have not yet recognized the expanded responsibilities that such personnel can and should discharge. To address this problem, the committee believes that all states should recognize nurses in advanced practice in their nurse-practice acts and delineate the qualifications and scope of practice of these nurses.

Ancillary Nursing Personnel

Today, almost all hospitals in the United States use some kind of ancillary nursing personnel. As stated in Chapter 4, this group of personnel includes nurses aides or assistants (NA), some of whom may be certified, as well as a variety of other ancillary personnel. By definition, they have less formal education and training than RNs or LPNs; on average, when hired they may also have

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