settings (Chaska, 1992; Kirchhoff, 1993), and both doctoral and postdoctoral research training should develop those competencies.
An extremely broad scope of practice is accorded physicians in some states, which makes it possible for the medical profession to occupy the entire health care field (Safriet, 1992). Barriers to practice (e.g., lack of prescriptive authority) and to reimbursement of APNs must be systematically removed. "In view of the serious access problems among poor and minority Medicare beneficiaries in urban areas, the continued systematic exclusion of nurse practitioners from Medicare is striking" (Aiken and Salmon, 1994, p. 323). Medicaid and Medicare laws should be revised to cover those services provided by APNs within their scope of practice.
Programs must be provided to renew displaced nurses. Such programs will, for example, develop severance packages that support additional education, enable nurses who have previously been hospital-based to learn how to work effectively in community settings, and help MSN graduates who are not certified as nurse practitioners to move quickly in that direction. Mandatory CE should be required and supported in all states, given the knowledge explosion and the quickening pace of changes in practice. Related to this is the obligation of universities and professional associations to provide CE programs on career assessment and the transformational leadership skills necessary in times of rapid change (Wolf et al., 1994a,b; Feldman, 1995). Relationships between employee and employer are much more explicit with regard to task outcomes and development expectations than they once were (Noer, 1993), and it is incumbent on nursing education both to prepare a work force capable of revitalizing itself in a time of fundamental organizational change and to act accordingly as it, too, becomes reconfigured.
In an article humorously entitled "Nursing Studies Laid End to End Form a Circle," Friss (1994) acknowledged that nurses have been one of the most studied groups in history, but that fundamental problems remain: no single route to entry into professional practice; lack of differentiated practice and corresponding salary compression; an impressive aggregate supply of nurses but the wrong educational mix; a scope of practice too often shaped by what others permit nurses to do rather than by what they can do; and periodic nurse shortages that lead to the attraction of casual workers rather than to a stable dedicated core. Her conclusion