received renewed attention, although public health nursing has always been a required component of baccalaureate nursing education.

At the core of the needs for future preparation of professional nurses is the requirement to continue to strengthen clinical decision making and clinical judgment skills. RNs will be called on to provide comprehensive care to a larger numbers of patients with more complex health situations. It is imperative that they be prepared for the complexities of patient care that they will confront.

Advanced Practice Nurses

Prepared as specialists in a clinical content area or generalists for primary care, advanced practice nurses (APN), including nurse practitioners, clinical nurse specialists, nurse midwives, and nurse anesthetists, require a firm foundation in the content areas identified above. Further, there may be some knowledge and skills of particular relevance to their specialty practice that would require even more depth in a particular area. The program content for APNs is currently being reviewed by specific accrediting bodies.

In summary, while there may not be total agreement on the adequate number and mix of type of nurses, there is general agreement that the preparation of both the current and the future nursing workforce must be enhanced.

Differentiated Practice

McBride (Part II of this report) has delineated the current and future issues of professional nursing education, indicating several major challenges that clearly need to be addressed if we are to see an appropriate use of professional nursing services in a restructured health care environment. Her call for differentiation of the RN workforce is supported by the work of Aiken (1994, 1995) and others (Koerner, 1992; Larson et al., 1994; Oermann, 1994a,b).

Differentiated practice using "care partners" appears to be the major restructuring activity that has occurred in 1994 and 1995. According to McBride (Part II of this report), the RN skill mix (that is, the proportion of RNs to other nursing staff) appears to be dropping in many settings, from a range of 76-100 percent to a range of 52-79 percent: "Cost effective care requires all health care providers to avoid duplication of effort and to make full use of the best, least expensive caregivers according to need." While these changes lead to uncertainties and concerns about job security for some, multiple career opportunities will continue to abound for those RNs skilled in health promotion and clinical decision making, and knowledgeable about community resources and the integrated delivery of care.

Throughout the site visits and in oral testimony, the committee heard of the need for more assessment of the capabilities of other care givers, along with the need for training in delegation and supervisory skills, which some RNs believed



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