Critical care nursing. Expanding roles and responsibilities within the community

The health care system in the United States is undergoing many changes, including the return of chronically dependent individuals who are medically fragile to the community's homes and schools. Community-based health care, when compared with hospital care, is more cost effective and is the consumer's preference. The supportive technology to perform skilled therapies is available and recent legislation, although not adequate, provides support. Not only is the community becoming an arena for the provision of more complex care, it is also becoming an arena for addressing ethical issues. The nursing profession is challenged to prepare skilled nurses for the greater independence that is required in community-based practice. Nurses need to become more aware of the authority inherent in their professional role in order to most effectively address and resolve the more complex and often intensive care needs of their clients who are medically fragile and being cared for in the community and to guide their families in the resolution of related ethical dilemmas.