EMERGING OPPORTUNITIES Within the traditional hospital setting, the levels of nursing hierarchy are established: vice president/director

r of nursing, nurse managers, and staff nurses. This hierarchy allow for promotion and advancement. Since the mid-1980s, however, the trend has been to flatten the levels of nursing management; that is, have fewer managers and additional clinical nurses including bedside nurses, nurses with expanded roles, and advanced practice nurse.

Certification Professional certification in nursing is a measure of distinctive nursing practice. This is an example of professional credentialing and is voluntary process undertaken by practicing nurses. The rise in consumerism in the face of a compelling nursing shortage and the professions movement to elevate nursing as a career option have given prominence to the value of certification in nursing ( Shirley, 2005). Basic eligibility requirements for specialty nursing certification often include the following: Hold a currently active RN licensure in its territories. Have practiced the equivalent of two years full-time as an RN. Hold a baccalaureate or higher degree in nursing. Note that candidates with an associate degree/ diploma may apply for certification in several areas of nursing practice. Have a minimum of 2000 hours of clinical practice within the past three years.

Traveling Nurse As the demand for nursing has increased, the supply has often been low, and hospitals are frequently understaffed. One option o fill the nursing shortage is traveling nurse. These nurses usually work in three-month assignments on the same unit. The benefits to the health care institution of using traveling nurses include having a nurse with a variety of experiences providing continuity of care for a three-month period. Traveling nurse need to be aware of differing nursing methodologies and licensure requirements from state to state and will require a license for each state in which they practice. Most travelers exhibit flexibility, adaptability, assertiveness, strong organizational and interpersonal skills, confidence, independence, and the ability to learn new skills and techniques.

Flight Nursing

In numerous tertiary care centers, nurses are functioning in the role of flight nurse for both helicopter and fixed-wing transports. Flight nursing actually started in 1933 with the emergency Flight Corps of the Armed Services which present in both the Korea and Vietnam wars. The concept of air ambulance was initiated in Denver in 1972. One needs numerous advanced technical skills to practice flight nursing, such as patient intubation, EKG interpretation, intravenous (IV) and chest tube insertion, medication administration, sedation, and central line placement. The vast majority of flight teams consist of an RN and respiratory therapist. Although there are no true national standards for becoming flight nurse, most of the opportunities available nationally require the following: Two to three years critical care experience Advanced Cardiac Life Support certificate (ACLS) Pediatric Advanced Life Support certificate (PALS) Neonatal Resuscitation Program (NRP) Graduation from a nationally recognized trauma program. Certification such as Critical Care Registered Nurse (CCRN), Certified Emergency Nurse (CEN), and Certified Flight Registered Nurse (CFRN) may also be required.

Health Care Sales/ Pharmaceutical Representatives Some nurses have left clinical staff nursing and have become representatives for companies that work in conjunction with traditional health care institutions. There are frequently many salary enhancement, or perks, given with these positions, including having a company car, going on business trips, attending national and regional meetings and conferences, participating in profit-sharing and stock option plans, and meeting a variety of health care personnel.

Case Manager The Case Management Society of America defines case management as a collaborative process which assesses, plans, implements, coordinates, and evaluates options and services to meet an individuals health needs through communication and available resources. The ANA defines goals of case management as providing quality health care along a continuum, decreasing fragmentation of care across many setting, enhancing the patients quality of life, and cost containment. In performing the role, the nurse care manager should have expert clinical skills and knowledge of the health care system, health care finances, and legal issues, as well as be an effective communicator. Nurse case managers must provide care that focuses on outcome achievement and assist in arranging, coordinating, and monitoring patient care services.

Nurse Entrepreneur Many nurses are leaving the bedside for the world of entrepreneurship in a variety of consultative, educational, or technical areas. The term entrepreneurship is an interpretation of a French word that means to undertake (Simpson, 1998). Merriam Webster Collegiate Dictionary describes an entrepreneur as one who organizes, promotes, and manages risk for an activity (2003). Some of the major characteristics and attributes of nurse entrepreneurs include te following: Are visionary, self motivated, and a risk taker Ave common sense Are good decision makers and problem solvers Are self confident, assertive, autonomous, and creative Are responsive to a perceived need Are market driven, with good financial foresight Recognize the possibility of success as well as the possibility of failure.

Wound, Ostomy, Continence Nurse Specialist In 1958 the field of enterostomal therapy was initiated at Cleveland Clinic, with the first enterostomal therapists (ETs) being nonnurses. The first nursing training program was started in 1961, and in 1972, new standards for the schools of enterostomal therapy were established. The year 1976 marked a significant change when the governing body of International Association of Enterostomal Therapists determined that only RNs would be admitted to enterostomal therapy educational programs. Nurses with this training and education practice both in hospitals and community-based settings such as visiting nurse associations, public health, nursing homes, and long-term care facilities. Over the past o years, these specialists have truly become the clinical experts in managing patients with ostomies, alterations in skin integrity, and wounds.

ADVANCED PRACTICE NURSING The concept of advanced practice nursing originated in the mid-to late nineteenth century, with the creation of the role of nurse anesthetist. The concept further developed in the twentieth century with nurse-midwifery, clinical nurse specialists, and finally, nurse practitioners. Why is there a need for advanced practice nurses (APNs)? The last quarter of the twentieth century taught that detection, prevention, early intervention, and education are not only cost-effective but also rational. APNs are ideally suited to deliver this type of health care.

In 1992, the ANA define APNs nurses who have a graduate degree in nursing and who conduct comprehensive health assessments, demonstrate a high level of autonomy, and possess expert skills in the diagnosis and treatment of complex responses of individuals, families, communities to actual or potential health problems. The AACN has provided a position statement that describes the APN as an umbrella term appropriate for a licensed registered nurse prepared at the graduate degree level with specialized knowledge and skills that are applied within a broad range of patient populations in a variety of practice settings. Are the APNs contributions unique and valuable, and can this be shown to others? Consider the following: o Clinical nurse specialist (CNS): In a hospital setting, the CNS must be able to identify how performance contributes to the patient-focused mission and goals of the organization. o Certified nurse midwife (CNM): The CNMs ability to better meet patients needs, or to provide services to groups of patients at a lower cost than services provided by practitioners, should be measurable. o Nurse practitioner (NP): In both inpatient and outpatient settings, the NP needs to document both the quantity and quality of services provided to patients and the NPs ability to reduce hospitalization. o Certified registered nurse anesthetist (CRNA): In evaluating anesthesia services in a chronic low back pain clinic, the CRNA should clearly document quality of service and patient outcomes. Clinical nurse specialist/Nurse practitioner (CNS/NP): A combined role Historically, the major differences between the CNS and NP were the settings and focus of their practice. The CNS role has been credited with creating an advanced level of nursing with an eye toward theory-based practice. The NPs have been credited with the movement of nursing beyond traditional roles and increasing the public awareness of advanced practice nursing. Following are some factors to consider when examining these two roles: Patient populations Future roles for CNS and NP Narrower perspective and focus for both the CNS and NP Horizontal violence within nursing nurses fighting among themselves.