Changes In Health Care System Research Articles

Impact of vertical integration in a referral-based healthcare system

Vertical integration has been growing steadily in healthcare and several studies have explored the impact of this phenomenon on prices, consumers, etc. In this work, motivated by changes in healthcare systems in China, we provide an operational perspective by investigating how vertical integration influences the referral behavior in primary care and the corresponding service provision at hospitals or specialists. We present an optimization model to explore the effect of different levels of vertical integration on generalists and specialists. We find that the healthcare system efficiency can indeed be improved with a moderate level of integration. However, when the level of integration increases beyond a certain threshold, healthcare costs may actually increase with more integration especially when generalists or primary care providers are inadequately trained and specialists are highly utilized. We find that full integration is not optimal. Moreover, aiming for a moderate level of integration is especially appropriate if the generalist’s ability to treat complex patients is limited and/or timely access to treatment is important. Our work also shows that physicians get higher payment without necessarily improving service quality when the integration level is higher. We discuss the implications of our results in the context of the Chinese healthcare system, although some insights may apply more broadly.

Diabetes Education Linked to Improved Patient Outcomes and Healthcare System Change.

Diabetes Education Linked to Improved Patient Outcomes and Healthcare System Change.

“It is not by choice that I gave birth at home”: the social determinants of home births during COVID-19 in peri-urban and urban Kenya, a qualitative study

BackgroundThe COVID-19 pandemic significantly impacted the provision of global maternal health services, with an increase in home births. However, there are little data on women’s decision-making and experiences leading up to home births during the pandemic. The objective of this study is to examine the economic, social, and health system factors associated with home births in Kenya.MethodsCommunity health volunteers (CHVs) and village leaders helped identify potential participants for an in-depth, one-on-one, qualitative telephone interview in Nairobi and Kiambu County in Kenya. In total, the study interviewed 28 mothers who had home births.ResultsThis study identified a number of economic, social, neighborhood, and health system factors that were associated with birthing at home during the COVID-19 pandemic. Only one woman had planned on birthing at home, while all other participants described various reasons they had to birth at home. Themes related to home births during the pandemic included: (1) unmet preferences related to location of birth; (2) burdens and fear of contracting COVID-19 leading to delayed or missed care; (3) lack of perceived community safety and fear of encounters with law enforcement; and (4) healthcare system changes and uncertainty that led to home births.ConclusionAddressing and recognizing women’s social determinants of health is critical to ensuring that preferences on location of birth are met.

Care and Treatment of Frail Older Adults in the Dental Office: A Case Report.

Population aging is a worldwide phenomenon that is changing healthcare systems globally, including dentistry. The percentage of frail older adults living in the community has increased as baby boomers age. The majority of these frail older adults are not edentulous, and require the services of a general dentist. Using a longitudinal case history, the authors have discussed the problems and decision making required to care for such an individual in a private dental office. We believe that with a better understanding of medicine and pharmacology, a general dentist should be able to develop a rational treatment plan for frail and dependent older adults who live in the community.

The trend of change in the role of pre-hospital emergency medical services in Iran’s healthcare system: a situational analysis

IntroductionFollowing the significant changes in healthcare systems over the last century, the role of pre-hospital emergency medical services (EMS) has been drawn against numerous challenges. In view of this, the present study aims to reflect on the trend of change in the role of pre-hospital EMS to meet new situations and needs, thereby providing a clear picture of this process.MethodsRespecting the intricate concept of development and the major changes in Iran’s healthcare system, this study was fulfilled using situational analysis (SA), developed by Clarke (2018), in Iran within 2022–2023. For this purpose, the data were collected through semi-structured, in-depth individual interviews with four faculty members, two managers involved in EMS, and six highly skilled EMS personnel in various positions. Moreover, the relevant articles published from 1950 to 2023 were reviewed. The data analysis was then performed via SA in the form of open coding as well as simultaneous analysis through three types of maps, viz., situational, social worlds/arenas, and positional maps, along with constant comparative analysis.ResultsPre-hospital EMS in Iran has thus far had two turning points from 1970 to 2023, wherein academic components, need for equipment and resources, in conjunction with basic needs in the modern society, have been the main propellers. As well, the complexity of care for non-communicable diseases (NCDs), demand for managed care, and technological advancement has gradually resulted in further development in EMS. This trend describes the EMS situation in Iran from 1973 to 2023, as well as the EMS emergence stages, quantitative growth and infrastructure, and clinical education development in 2002–2023, indicating the lack of funding and inadequate scientific infrastructure in proportion to the population receiving such services.ConclusionConsidering the trend of change in the approaches adopted by healthcare systems across the world, and given the breakthroughs in nursing and medicine, along the education of professionals during the last thirty years, the descriptions of duties and performance in EMS have moved from primary care and patient transfer to specialized services and outpatient care. In addition, the cultural context specific to Iran, the challenges of women working in EMS centers, the disconnection of service providers, namely, the Iranian Red Crescent Society (IRCS) Relief and Rescue Organization (R&RO), Iran’s National Police Force (INPF), and Iran’s National Medical Emergency Organization (INMEO), as well as lack of resources and equipment, and the geographical distribution of human resources (HRs) based on population dispersion, are thus among the significant issues facing pre-hospital EMS in this country.

Evaluating change in a pressured healthcare system: a cross-sectional study of implementation outcomes using routine data indicators and proxies

BackgroundImplementation evaluation should focus on implementation success, guided by theories and frameworks. With high staff vacancies in the health services, it is important to consider pragmatic methods of data collection for implementation evaluation. This paper presents a cross-sectional rapid evaluation of a handheld medical device designed for remote examinations, piloted in Northern England. By using downloaded device data and administrative records mapped to domains from the implementation outcomes framework, this evaluation offers a pragmatic example of assessing implementation success.MethodsThe pilot design was pragmatic: sites volunteered, decided which services to use the device in, and launched when ready. The pilot and evaluation together lasted 1 year. Data was downloaded from the devices, and administrative records for the pilot accessed. Variables were mapped to five of the implementation outcomes, after reviewing with the device manufacturer and pilot team to assess robustness.ResultsN=352 care episodes were recorded using the device with 223 patients. Out of 19 sites ‘signed up’ to the pilot, 5 launched and delivered 10 of 35 proposed projects: a site and project adoption rate of 26 and 29%, respectively. Six sites signed up to an extension period; three had launched and three had not during the original timelines, indicating some sustainability. Feasibility was high, with only one in seven care episodes needing to be repeated due to poor device quality or error (sound/audio/internet). Fidelity of device usage was low for two of the eight available device examinations. Device and staffing costs were high but potential cost savings were attributable to fewer in-person appointments.ConclusionsThrough using device and administrative data, this evaluation minimised burden on busy healthcare staff yet was still guided by an evaluation framework. Five out of the eight implementation outcomes were measured, including sustainability and costs. The findings give insight into implementation challenges, particularly around adoption. For future research, it is recommended to engage with staff to prioritise outcome measurements and to focus on meaningful interpretation of indicators.

Guest Editorial Special Issue on AIoMT-Enabled Federated Learning-Based Computing for Socially Implemented IoMT Systems: How Will Healthcare Systems Change?

Guest Editorial Special Issue on AIoMT-Enabled Federated Learning-Based Computing for Socially Implemented IoMT Systems: How Will Healthcare Systems Change?

The intersection of drug use discrimination and racial discrimination in the management of chronic non-cancer pain in United States primary care safety-net clinics: Implications for healthcare system and clinic-level changes

BackgroundClinicians’ bias related to patients’ race and substance use history play a role in pain management. However, patients’ or clinicians’ understandings about discriminatory practices and the structural factors that contribute to and exacerbate these practices are underexamined. We report on perceptions of discrimination from the perspectives of patients with chronic non-cancer pain (CNCP) and a history of substance use and their clinicians within the structural landscape of reductions in opioid prescribing in the United States. MethodsWe interviewed 46 clinicians and 94 patients, using semi-structured interview guides, from eight safety-net primary care clinics across the San Francisco Bay Area from 2013 to 2020. We used a modified grounded theory approach to code and analyze transcripts. ResultsClinicians discussed using opioid prescribing guidelines with the goals of increased opioid safety and reduced bias in patient monitoring. While patients acknowledged the validity of clinicians’ concerns about opioid safety, they indicated that clinicians made assumptions about opioid misuse towards Black patients and patients suspected of substance use. Clinicians discussed evidence of discrimination in opioid prescribing at the clinic-wide level; racialized stereotypes about patients likely to misuse opioids; and their own struggles to overcome discriminatory practices regarding CNCP management. ConclusionWhile clinicians and patients acknowledged opioid safety concerns, the practical application of opioid prescribing guidelines impacted how patients perceived and engaged with CNCP care particularly for patients who are Black and/or report a history of substance use. We recommend healthcare system and clinic-level interventions that may remediate discriminatory practices and associated disparities.

Здравоохранение российской Арктики: уроки пандемии COVID-19, результаты оптимизации, приоритеты развития

The COVID-19 pandemic has focused the attention of governments, international organizations, and the scientific community on the need to rethink the priorities and directions in healthcare development. The explosive increase in morbidity has exposed the problem of an acute shortage of basic healthcare resources, especially in the hospital sector. The importance of having a modern healthcare infrastructure and accessible medical care for the population has increased unprecedentedly, as these services are relevant to all countries and regions, including the Arctic territories. This study contributes to the scientific discourse on the problem of developing human resources and infrastructure for healthcare in the Arctic territories. The aim of the study was to analyze the main trends in healthcare personnel and infrastructure provision in the Russian Arctic over the past two decades and identify directions for further development in this field. The study used research methods such as logical and comparative analysis, as well as content analysis. The findings demonstrate that healthcare in the Russian Arctic is polarized, with personnel and infrastructure resources unevenly distributed and primarily concentrated in administrative centers. To solve the identified problems, it is necessary to design differentiated state policy mechanisms and implement a comprehensive national program for the development of healthcare in the Russian Arctic, improve access to healthcare in remote and sparsely populated zones, and engage business in personnel and infrastructure development. The practical significance of this study lies its potential to inform the development of customized approaches that account for Arctic characteristics in healthcare system modernization and public administration practices for social development in the Russian Arctic. The consequences of the pandemic and emerging global challenges associated with changing geopolitical and geoeconomic conditions and the socio-economic consequences of such changes require further research in this area, including the consideration of paid healthcare issues, the development of industrial medicine, and assessing the resulting impact of healthcare system changes on the health of Arctic populations

Health Policy and Governance in Pakistan

Health policy and governance play a pivotal role in shaping the healthcare landscape of a nation. In the case of Pakistan, a country with a diverse population and complex healthcare needs, effective health policy and governance are essential for achieving improved public health outcomes. However, numerous challenges persist, ranging from resource constraints to inequitable access to healthcare. A comprehensive examination of health policy and governance in Pakistan is crucial to identify areas of improvement and drive positive change in the country's healthcare system.
 Pakistan faces multifaceted challenges in health policy and governance. Limited financial resources, fragmented healthcare infrastructure, and a shortage of healthcare professionals pose significant hurdles to equitable access to quality healthcare services. Moreover, weak governance mechanisms and inadequate regulation contribute to inefficiencies and corruption within the healthcare system. These challenges disproportionately affect marginalized communities, exacerbating health disparities across the country.
 To address these challenges, a multi-pronged approach is necessary. First, there is a need for robust health policies that focus on primary healthcare, preventive measures, and targeted interventions for vulnerable populations. Policies should prioritize evidence-based decision-making, health promotion, and disease prevention strategies. Additionally, strengthening governance structures and regulatory frameworks is crucial to ensure transparency, accountability, and quality assurance within the healthcare sector.
 Furthermore, collaboration between various stakeholders, including government agencies, healthcare providers, researchers, and civil society organizations, is vital for effective health policy implementation and governance. The involvement of communities and marginalized populations in policy formulation and decision-making processes can foster inclusivity and ensure that policies address the specific needs of the population.
 Health policy and governance in Pakistan require significant attention and improvement to achieve equitable access to quality healthcare services and improved public health outcomes. This necessitates a comprehensive approach that encompasses evidence-based policies, strengthened governance structures, and multi-stakeholder collaboration. By addressing challenges such as resource constraints, healthcare infrastructure gaps, and inadequate regulation, Pakistan can create a healthcare system that is responsive, transparent, and capable of meeting the diverse healthcare needs of its population. Investing in robust health policy and governance is not only essential for improving public health in Pakistan but also a key driver of socioeconomic development and progress.

Портрет регионального министра здравоохранения – 2022

The heads of regional executive authorities in the sphere of health protection are key figures in the realization of the Russian Federation’s healthcare development strategy. Without qualified managers, it is difficult to achieve national goals and objectives of federal projects. The study of the qualifications, professional experience, and skills of the high leaders of regional health systems allows the evaluation of top personnel’s human potential and the successful implementation of steps to increase the efficiency of its administration. T h e a i m o f t h e s t u d y was to give a detailed information about regional health authorities managers in Russian Federation. M a t e r i a l s a n d m e t h o d s . A single-stage, continuous sociological study was planned and carried out using a specially developed questionnaire, which included a characterization of the accounting characteristics of participants’ age and demographic characteristic, level of basic and additional education, availability of professional competencies, and work experience in managerial positions. R e s u l t s . We achieved a response from 85 respondents. It was found that, as compared to 2021, there was a slowdown inside the process of rotation of regional ministers’ personnel and an increase in the degree of professional qualifications of managers in 2022. These trends were reflected in the increase in the average length of service in the position of regional minister (2021 2,1±1,9 years; 2022 2,6±2,5 years), the doubling of the number of managers with work experience of up to one year (2021 n = 42; 2022 n = 21), and the decrease in the number of managers with work experience of up to one year (2021 n = 42; 2022 n = 21). C o n c l u s i o n . The research allows for an assessment of the dynamics of changes in regional health care systems in terms of managerial human resources from 2021 to 2022. Positive declining trends in 2022 have been identified. The pace of rotation of regional ministers’ staff adds to the development of leaders’ professional abilities and experience and, eventually, will be the key to accomplishing strategic goals in health care.

Exploring the strategies used by Master Adaptive Learners in the planning of learning

Introduction: Due to changing health care system a learner has to re-establish prior knowledge to address current issues. A Master Adaptive Learner (MAL) utilizes a metacognitive approach to enhance the self-regulated learning which leads to an adaptive expertise development.Objective: To explore the strategies used by the Master Adaptive Learners in the planning of learning.Methods: A qualitative phenomenological study was carried out in 2021 May till to November in University College of Medicine and Dentistry. A total of five interviews were conducted, the number was restricted due to data saturation. Purposeful sampling technique was used to select doctors on head of department's recommendations as learners demonstrating exceptional performance during ward rounds and daily duties. Questionnaire was validated and piloted to ensure clarity.Interviews were recorded and transcribed verbatim. Confidentiality and anonymity was ensured.Results: Following themes were developed (1) Gap Identification: (a) Gaps in clinical practice (b) Gaps in teaching (2) Prioritization of Gaps: a) Prioritizing the patient (b) Prioritizing gaps in teaching (3) Identification of Resources. (4) Self-Regulation: (a) Scheduling (b) Self-awareness (5) Motivation: (a) Intrinsic (b) ExtrinsicConclusion: With the aim of providing a good healthcare system, the clinicians need a continuous learning- plan to effectively demonstrate adaptive expertise in routine practices. The current study concludes that the master Adaptive Learners use these five basic strategies that affect their planning and helps design learning opportunities to capitalize on these strategies through their role as coaches in the learning environment.Keywords: Learning, Master Adaptive Learner, Techniques

Career decisions, training priorities, and perceived challenges for anesthesiology residents in the United States

Study objectiveThis study sought to understand the timing and important factors identified by residents regarding their decision to pursue a career in anesthesiology, training areas deemed important to their future success, perceived greatest challenges facing the profession of anesthesiology, and their post-residency plans. DesignThe American Board of Anesthesiology administered voluntary, anonymous, repeated cross-sectional surveys to residents who began clinical anesthesia training in the U.S. from 2013 to 2016 and were subsequently followed up yearly until the completion of their residency. The analyses included data from 12 surveys (4 cohorts from clinical anesthesia years 1 to 3), including multiple-choice questions, rankings, Likert scales, and free text responses. Free responses were analyzed using an iterative inductive coding process to determine the main themes. Main resultsThe overall response rate was 36% (6480 responses to 17,793 invitations). Forty-five percent of residents chose anesthesiology during the 3rd year of medical school. “Nature of the clinical practice of anesthesiology” was the most important factor influencing their decision (average ranking of 5.93 out of 8 factors, 1 [least important] to 8 [most important]), followed by “ability to use pharmacology to acutely manipulate physiology” (5.75) and “favorable lifestyle” (5.22). “Practice management” and “political advocacy for anesthesiologists” (average rating 4.46 and 4.42, respectively, on a scale of 1 [very unimportant] to 5 [very important]) were considered the most important non-traditional training areas, followed by “anesthesiologists as leaders of the perioperative surgical home” (4.32), “structure and financing of the healthcare system” (4.27), and “principles of quality improvement” (4.26). Three out of 5 residents desired to pursue a fellowship; pain medicine, pediatric anesthesiology, and cardiac anesthesiology were the most popular choices, each accounting for approximately 20% of prospective fellows. Perceived greatest challenges facing the profession of anesthesiology included workforce competition from non-physician anesthesia providers and lack of advocacy for anesthesiologist values (referenced by 96% of respondents), changes and uncertainty in healthcare systems (30%), and personal challenges such as psychological well-being (3%). ConclusionsMost residents identified anesthesiology as their career choice during medical school. Interest in non-traditional subjects and fellowship training was common. Competition from non-physician providers, healthcare system changes, and compromised psychological well-being were perceived concerns.

Impact of COVID-19 pandemic in thoracic surgery training in Spain

In the more than 2 years since its emergence, the SARS-CoV-2 pandemic has prompted important changes in healthcare systems and their organization. The aim of this study is to determine the implications in specialized thoracic surgery training as well as the repercussions on thoracic surgery residents. With this objective, the Spanish Society of Thoracic Surgery has conducted a survey among all its trainees and those who had finished their residency during the last 3 years. It consisted of 24 multiple-answer closed questions about the impact of the pandemic on their services, their training, and their personal experience. The response rate was 42% (52 out of a target population of 120). The effect of the pandemic on thoracic surgery services was high or extreme according to 78.8% of the participants. Academic activities were completely cancelled in 42.3% of the cases, and 57.7% of the respondents were required to treat hospitalized COVID patients (25% part-time, and 32.7% full-time). More than 80% of the survey participants believed that changes during the pandemic negatively affected their training, and 36.5% would prefer to extend their training period. In sum, we observe how the pandemic has had deep negative effects on specialized training in thoracic surgery in Spain.

Impacto de la pandemia por COVID-19 en la formación de los cirujanos torácicos en España

In the more than 2 years since its emergence, the SARS-CoV-2 pandemic has prompted important changes in healthcare systems and their organization. The aim of this study is to determine the implications in specialized thoracic surgery training as well as the repercussions on thoracic surgery residents. With this objective, the Spanish Society of Thoracic Surgery has conducted a survey among all its trainees and those who had finished their residency during the last 3 years. It consisted of 24 multiple-answer closed questions about the impact of the pandemic on their services, their training, and their personal experience. The response rate was 42% (52 out of a target population of 120). The effect of the pandemic on thoracic surgery services was high or extreme according to 78.8% of the participants. Academic activities were completely cancelled in 42.3% of the cases, and 57.7% of the respondents were required to treat hospitalized COVID patients (25% part-time, and 32.7% full-time). More than 80% of the survey participants believed that changes during the pandemic negatively affected their training, and 36.5% would prefer to extend their training period. In sum, we observe how the pandemic has had deep negative effects on specialized training in thoracic surgery in Spain.

Generic Drug Development and Current Scenario

Drugs or medicines are those which are used for treatment, diagnosis, mitigation and prevention of diseases. But it’s very expensive. Not or all but for lower- and middle-class people taking treatment is very difficult because of the cost of the medicines. Many deaths are caused because the patient cannot afford the cost of the medicines. The entry of generic medicines in market brought a revolutionary change in healthcare system and the market share is continuously increasing. In the present scenario generic drugs have an important role in pharmaceutical market. Generic drugs are bioequivalent to brand drugs and are much cheaper as compared to brand drugs because of no R&D cost and minimum marketing expenses.This review presents considerations which can be employed during the development of a semisolid topical generic product. This includes a discussion on the implementation of quality by design concepts during development to ensure the generic drug product has similar desired quality attributes to the reference-listed drug (RLD) and ensure batch to batch consistency through commercial production.

Prognostic humility and ethical dilemmas after severe brain injury: Summary, recommendations, and qualitative analysis of Curing Coma Campaign virtual event proceedings.

Patients with severe acute brain injuries (SABI) are at risk of living with long-term disability, frequent medical complications and high rates of mortality. Determining an individual patient's prognosis and conveying this to family members/caregivers can be challenging. We conducted a webinar with experts in neurosurgery, neurocritical care, neuro-palliative care, neuro-ethics, and rehabilitation as part of the Curing Coma Campaign, which is supported by the Neurocritical Care Society. The webinar discussed topics focused on prognostic uncertainty, communicating prognosis to family members/caregivers, gaps within healthcare systems, and research infrastructure as it relates to patients experiencing SABI. The purpose of this manuscript is to describe the themes that emerged from this virtual discussion. A qualitative analysis of a webinar "Prognostic Humility and Ethical Dilemmas in Acute Brain Injury" was organized as part of the Neurocritical Care Society's Curing Coma Campaign. A multidisciplinary group of experts was invited as speakers and moderators of the webinar. The content of the webinar was transcribed verbatim. Two qualitative researchers (NK and BM) read and re-read the transcription, and familiarized themselves with the text. The two coders developed and agreed on a code book, independently coded the transcript, and discussed any discrepancies. The transcript was analyzed using inductive thematic analysis of codes and themes that emerged within the expert discussion. We coded 168 qualitative excerpts within the transcript. Two main themes were discussed: (1) the concept of prognostic uncertainty in the acute setting, and (2) lack of access to and evidence for quality rehabilitation and specialized continuum of care efforts specific to coma research. Within these two main themes, we found 5 sub-themes, which were broken down into 23 unique codes. The most frequently described code was the need for clinicians to acknowledge our own uncertainties when we discuss prognosis with families, which was mentioned 13 times during the webinar. Several strategies were described for speaking with surrogates of patients who have had a severe brain injury resulting in SABI. We also identified important gaps in the United States health system and in research to improve the care of patients with severe brain injuries. As a result of this webinar and expert discussion, authors identified and analyzed themes related to prognostic uncertainty with SABI. Recommendations were outlined for clinicians who engage with surrogates of patients with SABI to foster informed decisions for their loved one. Finally, recommendations for changes in healthcare systems and research support are provided in order to continue to propel SABI science forward to improve future prognostic certainty.

A changing supply chain for a changing health care system: Barriers and facilitators of implementing enterprise resource planning.

No studies have examined how health care mergers and acquisitions affected the hospital supply chain and its employees since the passing of the Patient Protection and Affordable Care Act. To describe the barriers and facilitators of digital transformation in a hospital supply chain from the employee perspective. We conducted two rounds of interviews, one year apart, with supply chain employees at an urban academic health system preparing to adopt an enterprise resource planning (ERP) software (N = 11 in Round I and N = 8 in Round II). Two researchers coded transcripts for themes using NVivo 11. We identified the following barriers to technology integration: silos between supply chain groups (e.g. Purchasing, Information Management, Strategic Sourcing), between employees and management, and resulting from prior mergers; focus on short-term problems and fear of change; and lack of transparent communication about upcoming changes. Facilitators of technology integration included motivation to work in supply chain; long-term vision that allowed tolerance of change and positive outlook; and transparent communication. Desire for shared leadership among employees emerged as a major theme, indicating the need for active involvement of employees during transition to new integrative technology.

Provider and Patient Experiences of Delays in Primary Care During the Early COVID-19 Pandemic.

The necessary suspension of nonacute services by healthcare systems early in the COVID-19 pandemic was predicted to cause delays in routine care in the United States, with potentially serious consequences for chronic disease management. However, limited work has examined provider or patient perspectives about care delays and their implications for care quality in future healthcare emergencies. This study explores primary care provider (PCP) and patient experiences with healthcare delays during the COVID-19 pandemic. PCPs and patients were recruited from four large healthcare systems in three states. Participants underwent semistructured interviews asking about their experiences with primary care and telemedicine. Data were analyzed using interpretive description. Twenty-one PCPs and 65 patients participated in interviews. Four main topics were identified: (1) types of care delayed, (2) causes for delays, (3) miscommunication contributing to delays, and (4) patient solutions to unmet care needs. Both patients and providers reported delays in preventive and routine care early in the pandemic, driven by healthcare system changes and patient concerns about infection risk. Primary care practices should develop plans for care continuity and consider new strategies for assessing care quality for effective chronic disease management in future healthcare system disruptions.

Position Statement on Cancer Nursing Leadership.

Position Statement on Cancer Nursing Leadership.