This paper discusses factors emerging from the health care reform movement that will shape health care service delivery in general and nursing practice and education in particular. First, cost concerns will increase moves toward managed competition which will, in turn, create changes in service use patterns. These patterns seem overall to tend toward decreased demand for professional nursing staff. These patterns will also eventually see nurses emerge with markedly different employment roles. One such role is likely to be a reshaped clinical nurse specialist role with nurses sometimes substituting for physicians. The current discontinuity between nurse practitioners' education and hospitals' desires to employ advanced practice nursing clinicians has seen a growing trend toward on-the-job training for acute care practice or toward development of acute care nurse practitioner training programs. One of the most important effects of health reform on nursing may be the need to define workforce supply in very different ways resulting in different workforce management and planning. Finally the paper argues that current and future medical research in genetic engineering will dramatically change health care decision-making, a change which nurses must be educated to handle. (JB)