sonnel are assigned directly to patients as if they operated on their own authority, rather than being assigned to nurses for delegation purposes.

High-level strategic planning for fundamental institutional change frequently does not include RNs, yet they are regularly expected to work out the operational details of restructuring, mergers, and consolidations. There is a move in many hospitals to incorporate nursing with other patient care services under a single vice president for patient care services. This has diminished the importance of the nursing director in the senior hierarchy, who was previously comparable to the medical director. Although nurses are best suited to take these new positions, the emphasis has shifted in many institutions away from the patient-care focus of nursing to "patient-focused care" which is sometimes used as a rallying cry for providing services at the lowest cost. These trends are disturbing because lower mortality has been associated with a higher ratio of RNs to patients (Hartz et al., 1989; Prescott, 1993) and with nurses having control over their practice (Aiken et al., 1994).

Advanced practice nurses are typically hired by physicians or administrators to staff a particular service and have no formal ties to nursing service delivery in other parts of the institution, so their connection to their profession can easily weaken over time, particularly if they are utilized only as physician substitutes rather than for their nursing expertise. The danger is that the growing use of APNs may replicate what happened to psychiatric clinical nurse specialists in the 1960s with the development of community mental health centers, when they were used as interchangeable members of the mental health team and consequently forsook nursing's traditional focus on maximizing functional ability in favor of "doing therapy" in 50-minute hours. As managed care systems grow in size across state boundaries, they have begun to push for institutional licensure to promote uniform practice, but such a move could further remove individuals from control over their profession's practice. Considerable legal and institutional barriers do exist to prevent reimbursement for nurse-provided primary care, for example, Medicare policies (Inglis and Kjervik, 1993).

Nursing may be in a more advantageous position in the universities of tomorrow for a number of reasons. The emphasis on service learning has made the activities of nursing students and faculty much more valued, particularly in those instances in which course requirements or contracted faculty time have benefited participating clinical or community agencies. The areas of scholarship that are being regarded with renewed appreciation—the scholarship of integration, utilization, and teaching—have been areas where nursing faculty have traditionally excelled. Nursing's accrediting body, the National League for Nursing, shifted to an outcomes orientation well ahead of other professional associations.

Nursing has a long history of being interdisciplinary; for example, the doctoral preparation of nurses has actively made use of the models of various disciplines such as ethics, education, anthropology, psychology, sociology, public health, and physiology. Nursing has never emphasized just regurgitating facts,



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