be needed in the future. Such training is essentially like that now provided for RNs who receive certification as, for example, advanced practice nurses.

Over the past 20 to 25 years, a number of studies have attempted to capture adequately the benefits of the clinical nurse specialist for the patients as well as for economic reasons. In particular, the evidence from several randomized clinical trials indicates that: clinical nurse specialists can foster high quality, cost-effective care especially for patients with complicated or serious clinical conditions care, and 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 concluded that the way should be clearer for such advanced practice nurses to be used in both inpatient and outpatient settings and for them to be able to take leadership positions and act independently. One obstacle to this, however, is found in the differing ways in which states recognize advanced practice nurses. 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.

Today, almost all hospitals in the United States use some kind of ancillary nursing personnel. In recent years the position of the nurse assistant (NA) has been changing. In some institutions they are assuming, under an RN's direction, increasing responsibility for more direct care activities than in the past. This results in rising levels of management and supervisory skills being required of RNs.

By definition, NAs have less formal education and training than RNs or LPNs. Far less information about employment trends is available on this group of the nursing workforce than on the more traditional nursing categories. No national standards exist for minimum training or certification of ancillary nursing personnel employed by hospitals. Furthermore, no accepted mechanism exists either to measure competency or to certify in some fashion that ancillary nursing personnel have attained at least a basic or rudimentary mastery of needed skills. The committee is greatly concerned about these lacks and the potential for adverse impact on patient care. It believes that hospitals should take the lead in ensuring that all ancillary nursing personnel employed by them have documented evidence of competency and appropriate training.

Culturally sensitive care will also become increasingly important in the years ahead. The population is not only aging but also is becoming more racially and ethnically diverse. Thus, increasingly, care givers and care receivers may come from different cultural backgrounds. The imperative for cultural sensitivity in training and practice is obvious.

The changes briefly described above are appealing conceptually, and time will tell if they are effective and practical as the hospital sector reinvents itself. In