These five recommendations provide a starting point for clinicians and patients to make decisions leading to higher-quality, lower-cost care. Future work is needed to promote adherence to these recommendations and to develop additional ways for intensive care clinicians to take leadership in reining in health-care costs.

Advanced practice nurses (APNs) have extraordinary opportunities in acute and critical care settings. However, new obstacles accompany these opportunities and these obstacles can needlessly hamper APN practice and reduce the APN's contributions to patient care. Contributions by APNs can be maximized by deliberately and thoughtfully creating a practice culture that is APN-friendly. This article analyzes eight characteristics important to creating the APN-friendly culture: clarity of vision and values, commitment, communication, collaboration, credibility, contributions, confidence, and complexity. Creating an APN-friendly culture is a worthwhile organizational investment in order to enhance optimal APN practice and to benefit patients and families.

High nursing turnover and a shortage of nurses in acute hospital settings in Sweden challenge health care systems to deliver and ensure safe care. Advanced nursing roles implemented in other countries have offered nurses new career opportunities and had positive effects on patient safety, effectiveness of care, and patient satisfaction. The advanced nursing position of Nurse Practitioner has existed for many years in the United States, while similar extended nursing roles and changes in the scope of nursing practice are being developed in many other countries. In line with this international trend, the role of Nurse Practitioner in surgical care has been proposed for Sweden, and a master's programme for Acute Nurse Practitioners has been in development for many years. To optimize and facilitate the introduction of this new nursing role and its supporting programme, we elicited the experiences and support of the group who developed a Nurse Practitioner programme for a university in the US. This paper describes this collaboration and sharing of experiences during the process of developing a Swedish Nurse Practitioner programme. We also discuss the challenges of implementting any new nursing role in any national health care system. We would like to share our collaborative experiences and thoughts for the future and to open further national and international dialogue about how best to expand the scope of practice for nurses in acute hospital care, and thereby to improve patient care in Sweden and elsewhere.

• Background Accreditation standards for certification programs require use of a testing mechanism that is job-related and based on the knowledge and skills needed to function in the discipline. • Objectives To describe critical care advanced practice by revising descriptors to encompass the work of both acute care nurse practitioners and clinical nurse specialists and to explore differences in the practice of clinical nurse specialists and acute care nurse practitioners. • Methods A national task force of subject matter experts was appointed to create a comprehensive delineation of the work of critical care nurses. A survey was designed to collect validation data on 65 advanced practice activities, organized by the 8 nurse competencies of the American Association of Critical-Care Nurses Synergy Model for Patient Care, and an experience inventory. Activities were rated on how critical they were to optimizing patients’ outcomes, how often they were performed, and toward which sphere of influence they were directed. How much time nurses devoted to specific care problems was analyzed. Frequency ratings were compared between clinical nurse specialists and acute care nurse practitioners. • Results Both groups of nurses encountered all items on the experience inventory. Clinical nurse specialists were more experienced than acute care nurse practitioners. The largest difference was that clinical nurse specialists rated as more critical activities involving clinical judgment and clinical inquiry whereas acute care nurse practitioners focused primarily on clinical judgment. • Conclusions Certification initiatives should reflect differences between clinical nurse specialists and acute care nurse practitioners.