n care and payment for services (Girard, 1993).
Reimbursement, billed under room and board in most hospitals, is designated only for nurses working in advanced patient care (nurse practitioners, clinical nurse specialists, nurse anesthetists). Other nurses now attempt to identify general tasks and activities for direct reimbursement. Difficulties include the constant redefinition of nurses roles, and the measure of intangible functions such as how to measure caring, support, coping, nonmedicinal pain control, decision making, and care planning. This shift takes decision-making power away from physicians and hospitals and may present opportunities for nurses. The nurse is now able to provide autonomous care with the ability to bill directly and be reimbursed (Girard, 1993).
Cohen and Wick (1995) comment on the Supreme Court's decision (1994) regarding the representation rights of nurses exercising supervisory authority on behalf of employers. This decision gives employers a new weapon, the power to remove supervisors from the union. Today's self-directed nurse faces conflicting messages; supervisors are terminated without warning, alienating the very employees whose cooperation determines the success or failure of the institution. It is viewed that these old attitudes must change to align with today's organizational structure which includes the importance of involving employees in the success of the organization.
The roles of nurses are changing. "The traditional sacrificing, undemanding, unquestioning, tireless workers have disappeared" (p. 484). Today nurses consider themselves to
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