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 coverage, funded by private underwriters and government entities alike, help explain the rise in the number of patients seeking access to care. By the 1960s, the care-delivery system had been well institutionalized: ôHospitals were the focus of care; physicians were in charge; providers told patients what to do; patients were dependentö (Healthcare, 1999). The effect of this entrenched, subsidized system, particularly after Medicare and Medicaid were instituted as a government-subsidized health-insurance systems for the elderly and the indigent, respectively, in the mid-1960s (General, 1997), was to conceal the costs of health care, which rose so dramatically during the 1970s and 1980s that by the 1990s they were simply beyond control. The health-care system responded to the crisis by focusing on costs and fostering a structural ôrevolutionö: ôFrom physicians to hospitals to managed care firms, the test in the years ahead is to continue to improve quality in the face of relentless cost pressure. As a society, we can no longer afford the enormous cost increases that character ized health care in the 1970s and ...