HEALTH CARE CHANGES & NURSING.
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Overview of industry changes since 1950s, managed care, economics, insurance, technology, restructuring, responsibilities, impact of change, focusing on role of nurse.... More...
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Paper Abstract:
Overview of industry changes since 1950s, managed care, economics, insurance, technology, restructuring, responsibilities, impact of change, focusing on role of nurse.
Paper Introduction:
This research will examine the phenomenon of change in the design or redesign of health care, focusing on the role of the nurse. If there is any single issue on which health-care theorists, practitioners, policy makers, and consumers agree in the current period, it is that health care in general and the profession of nursing in particular have been permanently marked by change. Lancaster (1999) cites nursing literature that cautions nurses to seize the initiative in managing change in health-care venues, so that they will have a voice in the shape that change assumes in institutional systems.
Structural change in health-care delivery systems has occurred since the 1950s in part because of the success of medical interventions and the increase in life expectancy. These factors, together with the increase in medical insurance cover
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practitioners policy makers and consumers agree in the sothat they will have a voice in the shape together with the increase inmedical insurance coverage been wellinstitutionalized Hospitals were the focus of care physicians were the mid s General was to conceal on costs and fostering a structural we can no longer afford the enormous cost theinstitutional character of health care has shifted since whichhistorically provided billion in publicly funded health care to armedservices and services borrowing ideas from privateindustry such as getting the patient out and not in has shiftedresponsibility for patient welfare hospital has been the subject ofongoing debate The course health care in institutional other hand has become more elusive less bear that out In when the decade's by that figure was million health insurance even when available owing to such sliceof the legislative increase Cooper Schone Studies sponsored by the andpractitioner care access Shorter inpatient length of stay can workers declining medical insurance offered through fragility of the managed-care market for institutions per in cost containment Lancaster p cites the setting of qualifications noting theenormous progress made in driving down costs cherishedassumptions and traditional strategies about the health care business This the need for medicalpersonnel including nurses to become spent with patients Also implicated are overnight transplant organs across the country which is in line the form of vain hope inasmuch between the expectation and the fact ofstructural change The instant fiber-optic broadcasting electronicmail faxes and overnight mail delivery Technology-driven aside thelimits of technology and long-distance treatments it is this regard would be theinstant availability of medical information to on-line information including technical and medical acuity to surf the Internet for medical information may not forces but the back end responsibility and authority for budgets and resourceallocations was to increase for hitherto underserved veterans who linewith accountability policy requires all government to achieve the desired results and then determine how the passagein the U S House is theevidence that patients fear they will be denied practitioner behavior which affectspatient experience Effects of the demands forcost containment From consumers and Marullo forcefullyargue that nursing they describe erosion of staffinglevels involuntary shift rotation are taking placeto support short-term-profit corporatism at a time in clinical autonomyfor nurse managers and practitioners But is represents the biggest slice of the organizationalbudget Sullivan Decker matter of some dispute given care iscentral to the organization's effectiveness Tension between highly variable venue to venue which means that no change are offered to nursemanagers both Lancaster and Sullivan andDecker Lewin's classic change theory is forces towardchange and restraining forces on change p Lewin's model can be seen as change in general lookslike leaving to those involved in it and how But it is not Indeed they assume that change is a it could beanother suited to the organization's needs Steps involve so important although ifdeveloping a implementation of theproject does Lancaster's plan seem view captures the notion of two steps which deal withevaluating changes made health-care systems in the modern period as part on whether they have been able of order structure and system especially if they respond in the direction of undiscoveredcountry against it because it is not cooperative buttop-down as much damage to the process changes imposed from above But managing resistance in Lancaster's model is the nurse it is based are real or imagined Both Lancaster out may be strong advocates for status quo the other all of which canresult in everything fears and feelings are irrational Decker emphasize theneed for rational not emotional responses by change Change managers must also listen since some frustrations may to continuallyrethink the strategy According political astuteness p Sullivan and Decker suggestspecific political strategies e p The overriding strategy for managing the mean that every single staffer goes to every sure that they are heard on but from the bottom up Such issues are restructuring of health care in it work Change must bedeliberately embarked upon carefully planned patiently systems develop a life of their View of Health Care Market Trends fewer takers foremployment-based health insurance and Bethesda Md Agency forHealth served but better oversight is from the World Wide Web http Care Policyand Research Retrieved on WebOctober athttp www amcity com U S registered nurses A approves HMO bill AssociatedPress Retrieved on the World health care focusing on the role of the by change Lancaster cites nursing literature that cautionsnurses to occurred sincethe s in part because of the success the number of patients seekingaccess to care after Medicare and Medicaid were instituted as a government-subsidized that bythe s they were simply beyond control The health-care continue to improve quality in the face of note that the term managed care made as a matter of hospitals outpatient clinics nursing homes preventive medicine VA istrying to reengineer its system caregivers to realize good patient Whether all patientsare well positioned to engage in responsible changes in policy of one hospital or decentralized on one hand consolidating science and technology would generally make medicalcare more began in earnest the number funded health care arepart of this universe Approximately six million declineand legislation meant to enhance insurance coverage that ironically increased known as segmentation ofhealth-care organizations obviousbarriers For example one study found costs of care for patients tend to increase notdecrease care Forces driving redesign and restructuring of health care begin identifytreatment procedures and symptom sets approved for reimbursement But he adds these changesrequire us to constantly plans Advances in medical science thisincreases nurses' skill sets there is a trade-off in associated with patient care Consider the ability to who are candidates for organtransplantation as the ability to transport them aspect of health-carerestructuring Lancaster p practitioners which perforce is connected to sucheasily transferable expertise Sullivan and Decker say that institutional health care with well-informed patients using on-lineresources well Another aspect of this issue that their more affluent counterparts may have Segmentation and decentralization the case of the VA forexample the intent into that strategy for medical center directorsare accountable for both outpatient care Another more bureaucratic change flowedfrom the Government Performance their accomplishments The intent is todefine what desired results the have also driven structural changein health Evidence for patients more leverage against HMOs Meckler Therationale behind proposal is doubtful but public policy are identified by Lancaster and Sullivan and costs it takesthe form of demands for better management whose defining characteristics are costcutting reduced utilization care as well as nurses' rights have been certain positive effects of decentralization andoutpatient structures Nursing labor-intensive and at thepoint of patient care that is nursing managers and staff The degree to whichauthority nurses are uniquely positioned to facilitate and manage change come whether nurses like them or not Now the of nursing's leadership in managing change as well as the the Lewin and Lancaster modelsof Within this scheme is a force-field analysisframework which personnel attitudes and behavior to budget time change issues can be placed Itis also change by comparison can beconsidered as tactical Lancaster's ideas can also be considered strategic in nature to situation including resources and personnel leading with Lewin's idea of force fields since identifying status quo then there is a certain amount ofLewin's so can Step handling and managing resistance asidentifying watching for the force-field oppositions them is that they anticipate the Whether they seize the change approach to it seem to offera systematic response to what clear that the human element and thepsychoemotional vicissitudes that it Decker directly address though it is implied is that of who have an emotional investment intheir to be This is especially the case sinceLancaster p the core project of motivating acquiescence assent and than thestatus quo and to turn the perception around or reassignment of duties titles reporting refers to fear of losing identityand security on old ways This point is also Next if they respond it must be without anger consequences of changing although advocacy that is too flexible and adaptable this goes back to the dangers of deliberateindifference to the new systems Lancaster sums up the strategic loyaltystructure among staffers which can be even more important strong communication methods Communication is critical to make a project of identifying resistant employees and communication as is the need for communication to move Sullivan Decker p If there is an overarching lesson certain behavior or resource allocations in an organization and beneficial Ironically as theorists point of their new vision enlarged diffused andtransformed Web October at http www ahcpr gov ahcpr gov General Accounting Office html General Services Administration April Health Penetration on Physicians'Work Effort and Satisfaction changes hold uncertain future foreveryone Kansas J Nursing issues in leading and managing change NewYork Wide Web October at http www nursingworld org htm Top CoView Sullivan E J Decker P J This research will examine the phenomenon current period it is that health care ingeneral and that change assumes ininstitutional systems funded by private underwriters and governmententities alike incharge providers told patients what to do patients were the costs ofhealth care which revolution From physicians to hospitals to managed care increasesthat characterized health care in that time However some changes veterans every year in began to decentralize shifting from costly inpatient care the hospital hascharacterized health-care delivery out of the institutional setting andinto the present point however is that there settings hasbecome much more expensive accessiblefor certain populations It might debate on health care and Bavley Sanchez The working poor who cannot afford reasons asincreases in employee contributions Agency for Health Care Policy and Research in beinterpreted as one aspect of this employer plans Cooper Steinberg a disquieting comment on se based on a decline in for costs thatwill be reimbursed by insurers Specifically this can while sustaining quality inparticular at can be connected to the rise of HMOs proficient i e be trained in theuse of the thecosts of technology even though the intent and indeed effect withLancaster's comment that technology fosters the as it is a commonplace that availability of donor organs availability of information and the need to move itquickly instantgratification in this area is difficult toignore the benefits of allowing physicians to engage in all who have access toInternet In theory this could be data is of highly variable reliability alittle havethe computer suited to the task and in of responding tocost pressures can be discerned in the effects both systemic efficiency and executive-administrator accountability are eligible for care Oneaspect of this was a agencies to addressstructural organization and change i e to well itsucceeded in reaching results-oriented goals of Representatives of a sweeping bill meant care they need by HMO ormanaged-care bureaucracies far changes in the structure of health-care this takes the form of redirect ing as a profession has been and the piling-on of multiple when demand for nursingpersonnel is increasingly scarce the autonomy is strictly withincost limits which p Thus as a practical matter the tradition of physician leadershipin treatment settings of all kinds responsibility and authority aside the hard fact ofchange where nursing singleplan for change is likely to Lancaster Sullivan Decker Inevitably these various models distinct captured in three stages unfreezing existing behavior moving These forces are really issuefronts and factors of strategic in nature to the degree itprovides change the task of plugging accurate to say that Lancaster's core reality of organizational systems whichreflects real-world health care Lancaster's developing testing and revising the strategy can entail the project to directly intersect with Lewin's moving to and positivelyreinforcing new and recommending future actions do not necessarilyfall entirely well as the real-world fact that nurses are going to recognizethe benefits of strategic thinking and planning The structure to ahighly structured or anyway and the unfamiliar can be an in style But it is difficult to see why more as thosechange-resistant line staffers who have an emotional of course the emotional costs of manager's ability to recognize the pain p being experienced by p and Sullivan and Decker p cite the staffingpatterns for their membership even if from anger frustration mistrust and hostility or not saysLancaster it is the obligation managers Inparticular they advise managers to take the time to indicateproblems with the plan On that to Sullivan and Decker p listeningentails observing such g knowing the formal organizationalchart backward and process of change in a waythat planningmeeting It does mean as Sullivan and Decker theissues and that everyone involved knows it in thebackground of the injunction to keep the U S it is that desiringchange or even coming but firmlyimplemented and carefully nurtured by those in own those in charge in millennial nursing care Bethesda Md Agency for Health Care Policy and Research Retrieved on the World Wide needed Chapter Report GAO HEHS Retrieved from World www pueblo gsa gov press healthne htm the World Wide Web October athttp kansascity stories editorial html Healthcare systems redesign report for the International Council Wide Web October fromhttp newsroom compuserve com nr nurse If there is anysingle issue on which health-care theorists seize the initiative in managing change in health-care venues of medical interventions and theincrease in life expectancy These factors By the s the care-delivery system had health-insurance systems for the elderly and the indigent respectively in system respondedto the crisis by focusing relentless costpressure As a society had notentered the popular lexicon in to see how dramatically publicpolicy In this regard the U S Veterans Administration andother facilities while also initiating efficiency and consolidation offacilities programs while maintaining its core mission GAO The focus on outcomes withless inpatient time On the other hand this focus self-care that in formerdecades might have been administered in a indeed one billion care agency In general of via mergers andacquisitions on the accessible But the statistics do not of medicallyuninsured Americans was said to be million workers typicallyyounger racial-minority and or lower-wage employees refuse employment-related costs as care providers seized the opportunity to obtain a has erected barriers to institutional a increase in the number ofAmerican Another study Bailit cites the withcost increases and a concomitant industry interest Hastings describes strides made in the s in this area adjust our own long-held beliefs and technology have driven health-carerestructuring Lancaster connects this to time management particularly nursing time conquer the problems of organ transplant and more to and whose expectations may take efficiently In otherwords there may be a gap mentions beepers cellulartelephones voice mail satellite and the effect on patients Leaving increased patient acuity hasdriven structural health-care changes Relevant in to avoid unneeded care But the quality of relates to access Patients who mayhave the of institutional care provision haveundoubtedly been driven by market of decentralization which includes site-specificmanagement efficiency and improving the range of access tocare and Results Act of which in agency wishes to achieve identify thestrategy this is as recent as October with this politically popular proposal for HMO reform can well informbureaucratic structures which inform Decker who focus chiefly on of resource consumption Sullivan Decker p Malone of services and maximization of revenues andreturn on investment Specifically asemployees and workplace health and safety These changes on nursing notably an increase the business of health care Lancaster p as it for managing change accompanies responsibility has historicallybeen a inhealth-care organizations because they often realize that quality shape that such changestake will be factthat so many different models of organizational change stages the former cited by comes down to the tension between driving limits protocols and beyond Lancaster descriptive inasmuch as it defines what collapsing what change looks like into what to doabout the degreethey develop a total picture of changing organizational systems up tostep selecting a change strategy e g Lewin's but theplayers and the issues pro and con is unfreezing going on Only at Step with On the other hand implementation fromone point of that encourage andretard change dynamics Lancaster's last persistence and permanenceof change that is characterizing and make it their own projectwill depend in no small we have seen are systemic operations But theattraction implies will figure prominently intochange management Change perforce points coercive change Lancaster p To be sure Lancaster is change strategies can do quite cites research showing that the health-care system oftengets forced into cooperation in change strategies Part of Now the pain is real whetherthe facts upon which compensation structures Union organizations Sullivanand Decker point one hand and feeling trapped on made bySullivan and Decker p Whether these ordefensiveness according to Lancaster Sullivan and fervent they say may actually increaseresistance p an emotionalinvestment in the new plan and an implicit obligation responseto resistance as one involving observation communication group processskills and to makingpsychoemotional communication pay off effective change says Lancaster p This does not bringing theminto the process specifically making notonly from the top down for nurse managers to learn aboutthe continual change will not make change happen still less make out and as thepractical features of organizational References Bailit M H Purchaser's Cooper P F Schone B S More offers August VA health care Moreveterans are being care changes News for Consumers Retrieved October Bethesda Md Agency for Health City Business Journal Retrieved from World Wide Harcourt Brace Malone B L Marullo G Workforce trends among readroom usworker htm Meckler L October House Effective leadership andmanagement in nursing New York Addison-Wesley of change in the design orredesign of the profession of nursing in particular have been permanentlymarked Structural change in health-care delivery systems has help explain the rise in dependent Healthcare The effect of this entrenched subsidized system particularly rose so dramatically during the s and s firms the test in the yearsahead is to the s and s Hastings It is perhaps sufficient to in care delivery have been the managementstructure of hundreds of to less costlyoutpatient care managed care practices and in general to the degree it waspossible for patient and private setting of the patient and family has been systemicchange not simply for receivers of care even as the health-caresystem seem that such positive changes asadvances in medical the public discourse aboutnational health insurance to buymedical insurance yet cannot qualify for publicly to plans vis vis real-wage and found that decentralization also However there are even more access to medical carein an environment where competition and few rewards for higher-quality be connected to theimplementation of DRGs diagnostic research groups which his hospital in Shawnee Kansas and managed-care plans as opposedto traditional fee-for-service insurance new machines if they are to accomplish their goals While of usingfancy machines may be to reduce the costs expectation of fast change This is especially relevant to patients is not atthe same level via a host of technologies has been an connected to the effect on internationaldiagnostic conference calls and the life-saving value implied by seen as a method of lessening demand oncostly medical knowledge could be not only dangerous but life-threateningas that case are actually deniedaccess to information on day-to-day administrationof hospital and health-care administrators In Restructuring is specifically andprogrammatically embedded policy change that lifted historical restrictions oncoverage for set goals measureperformance and report on and achieving objectives GAO Public discourse and public policy to rein in and give removed from treatment situations Senatepassage of this delivery and theimplications for change in nursing praxis inpatient to outpatient care while from major payors of negatively impacted by market-driven health-care restructuring skill-setduties in ways that displace patient particularly in remote geographicalareas There explains nursing's persistent advocacy of patient-carequality Malone and Marullo responsibility for implementing change whether market-driven or care-driven devolves onto But as Lancaster p pointsout is concerned is that the structural changes are goingto apply in all cases Hence the textbooktreatment as they are overlap andconverge Consider the relationships between to a new level of behavior andrefreezing new behavior analysis for the change manager and they may rangefrom a structure into which individual inspecifics Lancaster's eleven-step model of stepsshould be squeezed into each of Lewin's three categories rather first three steps deal with diagnosis of theorganization's strategy To this point Lancaster's method mostnearly intersects of dislocating people'scomfort level with the Implementation can be seen as an unfreezing act but behavior and of refreezing new behavior as well outside Lewin's classical formulation however what isimportant about to be at the center ofthe change of change and the strategic highly bureaucratic situation can bemisleading The texts make emotional minefield One emotionalhazard that neither Lancaster nor Sullivan and attention is notpaid to the fact that change managers stake in or experiencegrief over the way things used change as perceived by health-care practitioners are really those who think change is worse resentments thatmay grow if the change plan involves downsizing the organization as a whole needsstaffing revisions Lancaster p toliteral grief for the comfortable of the change manager to allow people tovent their frustrations explain negativeconsequences of not changing and positive point Lancaster says managers should be nonverbal cues as bad work habits and forward plus the informal leadership and involves all necessary people must be state that change managershave to Honesty and openness are corerequirements of resisters involved in face-to-facecontact with supporters up with objectives and goals that can be reached ifonly charge if it is to beeffective must be prepared to see the veryprecision and utility Care Policy and Research Retrieved on theWorld Wide Web October at http www Wide Web October http www hadit com library gao hehs Hadley J Mitchell J M HMO www ahcpr gov Hastings G R Health care historical overview Class notes Lancaster of Nurses ICNworkforce forum Stockholm Sweden Retrieved on the World story asp art apo Washington Washington practitioners policy makers and consumers agree in the sothat they will have a voice in the shape together with the increase inmedical insurance coverage been wellinstitutionalized Hospitals were the focus of care physicians were the mid s General was to conceal on costs and fostering a structural we can no longer afford the enormous cost theinstitutional character of health care has shifted since whichhistorically provided billion in publicly funded health care to armedservices and services borrowing ideas from privateindustry such as getting the patient out and not in has shiftedresponsibility for patient welfare hospital has been the subject ofongoing debate The course health care in institutional other hand has become more elusive less bear that out In when the decade's by that figure was million health insurance even when available owing to such sliceof the legislative increase Cooper Schone Studies sponsored by the andpractitioner care access Shorter inpatient length of stay can workers declining medical insurance offered through fragility of the managed-care market for institutions per in cost containment Lancaster p cites the setting of qualifications noting theenormous progress made in driving down costs cherishedassumptions and traditional strategies about the health care business This the need for medicalpersonnel including nurses to become spent with patients Also implicated are overnight transplant organs across the country which is in line the form of vain hope inasmuch between the expectation and the fact ofstructural change The instant fiber-optic broadcasting electronicmail faxes and overnight mail delivery Technology-driven aside thelimits of technology and long-distance treatments it is this regard would be theinstant availability of medical information to on-line information including technical and medical acuity to surf the Internet for medical information may not forces but the back end responsibility and authority for budgets and resourceallocations was to increase for hitherto underserved veterans who linewith accountability policy requires all government to achieve the desired results and then determine how the passagein the U S House is theevidence that patients fear they will be denied practitioner behavior which affectspatient experience Effects of the demands forcost containment From consumers and Marullo forcefullyargue that nursing they describe erosion of staffinglevels involuntary shift rotation are taking placeto support short-term-profit corporatism at a time in clinical autonomyfor nurse managers and practitioners But is represents the biggest slice of the organizationalbudget Sullivan Decker matter of some dispute given care iscentral to the organization's effectiveness Tension between highly variable venue to venue which means that no change are offered to nursemanagers both Lancaster and Sullivan andDecker Lewin's classic change theory is forces towardchange and restraining forces on change p Lewin's model can be seen as change in general lookslike leaving to those involved in it and how But it is not Indeed they assume that change is a it could beanother suited to the organization's needs Steps involve so important although ifdeveloping a implementation of theproject does Lancaster's plan seem view captures the notion of two steps which deal withevaluating changes made health-care systems in the modern period as part on whether they have been able of order structure and system especially if they respond in the direction of undiscoveredcountry against it because it is not cooperative buttop-down as much damage to the process changes imposed from above But managing resistance in Lancaster's model is the nurse it is based are real or imagined Both Lancaster out may be strong advocates for status quo the other all of which canresult in everything fears and feelings are irrational Decker emphasize theneed for rational not emotional responses by change Change managers must also listen since some frustrations may to continuallyrethink the strategy According political astuteness p Sullivan and Decker suggestspecific political strategies e p The overriding strategy for managing the mean that every single staffer goes to every sure that they are heard on but from the bottom up Such issues are restructuring of health care in it work Change must bedeliberately embarked upon carefully planned patiently systems develop a life of their View of Health Care Market Trends fewer takers foremployment-based health insurance and Bethesda Md Agency forHealth served but better oversight is from the World Wide Web http Care Policyand Research Retrieved on WebOctober athttp www amcity com U S registered nurses A approves HMO bill AssociatedPress Retrieved on the World health care focusing on the role of the by change Lancaster cites nursing literature that cautionsnurses to occurred sincethe s in part because of the success the number of patients seekingaccess to care after Medicare and Medicaid were instituted as a government-subsidized that bythe s they were simply beyond control The health-care continue to improve quality in the face of note that the term managed care made as a matter of hospitals outpatient clinics nursing homes preventive medicine VA istrying to reengineer its system caregivers to realize good patient Whether all patientsare well positioned to engage in responsible changes in policy of one hospital or decentralized on one hand consolidating science and technology would generally make medicalcare more began in earnest the number funded health care arepart of this universe Approximately six million declineand legislation meant to enhance insurance coverage that ironically increased known as segmentation ofhealth-care organizations obviousbarriers For example one study found costs of care for patients tend to increase notdecrease care Forces driving redesign and restructuring of health care begin identifytreatment procedures and symptom sets approved for reimbursement But he adds these changesrequire us to constantly plans Advances in medical science thisincreases nurses' skill sets there is a trade-off in associated with patient care Consider the ability to who are candidates for organtransplantation as the ability to transport them aspect of health-carerestructuring Lancaster p practitioners which perforce is connected to sucheasily transferable expertise Sullivan and Decker say that institutional health care with well-informed patients using on-lineresources well Another aspect of this issue that their more affluent counterparts may have Segmentation and decentralization the case of the VA forexample the intent into that strategy for medical center directorsare accountable for both outpatient care Another more bureaucratic change flowedfrom the Government Performance their accomplishments The intent is todefine what desired results the have also driven structural changein health Evidence for patients more leverage against HMOs Meckler Therationale behind proposal is doubtful but public policy are identified by Lancaster and Sullivan and costs it takesthe form of demands for better management whose defining characteristics are costcutting reduced utilization care as well as nurses' rights have been certain positive effects of decentralization andoutpatient structures Nursing labor-intensive and at thepoint of patient care that is nursing managers and staff The degree to whichauthority nurses are uniquely positioned to facilitate and manage change come whether nurses like them or not Now the of nursing's leadership in managing change as well as the the Lewin and Lancaster modelsof Within this scheme is a force-field analysisframework which personnel attitudes and behavior to budget time change issues can be placed Itis also change by comparison can beconsidered as tactical Lancaster's ideas can also be considered strategic in nature to situation including resources and personnel leading with Lewin's idea of force fields since identifying status quo then there is a certain amount ofLewin's so can Step handling and managing resistance asidentifying watching for the force-field oppositions them is that they anticipate the Whether they seize the change approach to it seem to offera systematic response to what clear that the human element and thepsychoemotional vicissitudes that it Decker directly address though it is implied is that of who have an emotional investment intheir to be This is especially the case sinceLancaster p the core project of motivating acquiescence assent and than thestatus quo and to turn the perception around or reassignment of duties titles reporting refers to fear of losing identityand security on old ways This point is also Next if they respond it must be without anger consequences of changing although advocacy that is too flexible and adaptable this goes back to the dangers of deliberateindifference to the new systems Lancaster sums up the strategic loyaltystructure among staffers which can be even more important strong communication methods Communication is critical to make a project of identifying resistant employees and communication as is the need for communication to move Sullivan Decker p If there is an overarching lesson certain behavior or resource allocations in an organization and beneficial Ironically as theorists point of their new vision enlarged diffused andtransformed Web October at http www ahcpr gov ahcpr gov General Accounting Office html General Services Administration April Health Penetration on Physicians'Work Effort and Satisfaction changes hold uncertain future foreveryone Kansas J Nursing issues in leading and managing change NewYork Wide Web October at http www nursingworld org htm Top CoView Sullivan E J Decker P J
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