Evolving changes in the health care environment are driving the need for nurses with higher educational qualifications. Changes in the health care system, financial responsibility shifts, technical medical advances, and medical care rationing are among the factors that are driving health care providers of all stripes toward affiliations that in turn become health care systems (Tong, 1995). Important within the context of higher educational requirements for nurses is the trend of hospitals to transform themselves into health care systems. These systems require personnel, especially nurses, with educational and managerial qualifications that surpass existing standards.
Changes in reimbursement, medical practice, demographics and lifestyles are altering profoundly the way providers relate to hospitals (Hagland, 1991). As a consequence, hospitals need to form much closer relationships with provider group practices and managed care groups to ensur
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