ractitioner has been evolving from a medical to a nursing orientation since the inception of role in 1955 (Thibodeau & Hawkins, 1994, pp. 205-218). As a result of the combination of factors (increasing costs of health care, changing societal values, advances in treatment therapies, and many others), the delivery of health care services in the United States is undergoing rapid and important change. One of the more significant of the changes occurring involves the direct delivery of health care services by non physician health care professionals. There exists both substantial support for this trend, as well as substantial opposition to it (Hupcey, 1993, pp. 181-185). Nurse practitioners and clinical nurse specialists are among the most prominent of the non physician health care professionals involved in the direct delivery of health care services to patients.
Nurse practitioners and clinical nurse specialists engage in the delivery of a wide variety of health care services without the direct supervision of physicians (Thibodeau & Hawkins, 1994, pp. 205-218). The early role of the nurse practitioner was primarily as a member of a primary health care team. This role continues to be important in the 1990s, although the function of the nurse practitioner has expanded far beyond this concept.
In the 1990s, the nurse managed clinic frequently serves as a focal point for primary health care (Reifsteck & D'Angelo, 1990, pp. 12-21). As a focal point, the nurse managed clinic is the hub through which all health care services for patients may be arranged. Within this context, the assumption of additional responsibilities by nurse practitioners and clinical nurse specialists has been found to be effective in the combined context of cost containment and improving care quality (Manion, 1991, pp. 18-21; Behner & Hagerott, 1991, pp. 30-34).
In the 1990s also, government has found that nurse practitioners and clinical nurse specialists c...