plore practice plans, contracts with local agencies, and continuing education for professionals and the public alike as possible new revenue streams.
Like the health care delivery system, higher education is increasingly sensitive to community need, focused on performance-based outcome measures, and concerned about differentiated faculty roles with a concomitant reliance on some mix in expertise. Data management systems assume a new importance in an environment concerned about policy-making to achieve efficiency and effectiveness. New initiatives are increasingly being funded by redirecting existing resources rather than acquiring new ones from traditional public sources. The lifting of mandatory retirement requirements has created an additional concern about whether the faculty in place have the skills and knowledge base needed for the future.
With the two social institutions of health care delivery and higher education undergoing such fundamental change, nursing will have distinct advantages and disadvantages. In the reconfigured health care delivery system, nursing has much to offer: a comfortableness about operating within systems; conceptual models capable of analyzing the person-environment fit; a family-centered care focus; a history of interdisciplinary collaboration; community assessment skills; experience with health promotion and consumer education; the ability to span boundaries; a nonreductionist philosophy of care; relationship-centered care (Tresolini and the Pew-Fetzer Task Force, 1994); established links with community agencies and long-term care facilities; long-standing encouragement of functional ability and quality of life; expertise in behavioral outcomes research; and several hundred community-based nursing centers attached to schools of nursing. In a reconfigured health care delivery system, a major advantage is that the cost of educating an APN may be as little as one-third of the cost of physician training, and that nurse practitioner can provide about 80 percent of primary care services at an equivalent level of positive outcomes and patient satisfaction (Pew Health Professions Commission, 1994a,b).
Nursing also is disadvantaged in the reconfigured health care delivery system. The downsizing of hospitals is displacing RNs more than any other worker, and those in place may be more prone to burnout because of increased workload (McClure, 1991; Gordon, 1995). Many of the changes that are taking place are not based on tried-and-true principles, but on a frustration with current realities. The downsizing of nursing within hospitals is also taking place at the same time that nurses are being expected to supervise the work of more unlicensed assistive personnel, which is itself a time-consuming task (ANA, 1992). Joel (1994) has noted that coordination of care is further complicated when these assistive per-