most often performed by an RN, frequently one who has been prepared with education beyond the basic program of nursing. In most hospitals the nursing case manager is the person who spans the boundaries of inpatient, ambulatory, and community nursing (Girard, 1994).

In summary, the dynamics of staffing and scheduling in hospitals, always more complex than one would expect, have taken on even greater complexities as care giving becomes much more interdisciplinary in nature and care givers are required to consider more than the event of illness presented, that is, the current hospitalization or the current outpatient visit. The continuum of care, sharing of information across the system, and the increasing involvement of patients and families in their own care giving requires that staffing be considered in its broadest definition.

Evolving Roles in Advanced Practice Nursing

The committee takes note of the growing trend toward complexity of illness and sophisticated care management of patients in an illness episode that includes the event of hospitalization but is not limited to it. The care planning and managing begins before the patient is admitted to the hospital and continues beyond the hospitalization to discharge planning and management of care needed after discharge from the hospital. Leading and managing the organizational transformations described above require talents or training that not all RNs now have. For the evolving hospital, the committee believes that it will be imperative for these management and leadership skills to be fostered through various educational programs. The committee believes that more advanced, or more broadly trained, RNs will be needed in the future. Such training is essentially like that now provided for RNs who receive certification as, for example, advanced practice nurses (i.e., clinical nurse specialists, nurse practitioners, nurse midwives, and nurse anesthetists).

Clinical nurse specialists can be found in every specialty area of nursing. In each of these areas clinical nurse specialists function as practitioners, educators, case managers, consultants, researchers, and administrators; in the mental health arena, they may also serve as psychotherapists. They play a critical role in the ongoing clinical management of caseloads of patients. Nurse practitioners manage patients with acute and chronic conditions. They frequently have responsibility for managing patients with illness such as diabetes or hypertension. They also are responsible for the ongoing primary care of a group of healthy individuals.

The value of such clinical nurse specialists, in terms of both patient care and economic factors have been studied over the past 20 to 25 years. In particular, a number of randomized clinical trials have been conducted.

One set of studies was directed at testing the effectiveness of programs conducted by clinical nurse specialists in caring for hospitalized elderly patients,



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