The articles in this issue once again demonstrate the wide range of issues with which health managers and researchers are faced. Health services managers must contend with the wide range of strategic and operational issues that are addressed in the field of management and faced by any firm regardless of industry. However, because they manage health care organizations, they face an equally wide range of issues that reflect the external pressures and internal characteristics unique to the health care industry. Among these are the professionals who are responsible for the technical core of the organization, and the ambiguity inherent in measuring performance.

The articles in The FORUM and the article by Bret Simmons and Debra Nelson, "Eustress at Work: The Relationship Between Hope and Health in Hospital Nurses" address important questions about professionals. Henry Mintzberg has described professional organizations as ones in which those who manage the technical core embody skills that are independent of the organization. Thus the physician, by virtue of specialized training, makes decisions that reflect to a large part practice as defined by the profession, and not by the organization. Because of the importance of physicians to virtually all aspects of the health care delivery system, considerable attention has been paid to understanding the nature of physicians' work. And as so frequently occurs when considering questions of importance, different perspectives have developed. The FORUM provides an opportunity to explore some of those perspectives, and to consider what assumptions underlie different approaches.

All too frequently, discussions of professionals in hospitals seem to assume physicians. Yet nurses are a critical professional resource in health care organizations, and research that focuses on their role, and the managerial implications, are of great importance. Whether considered in terms of impact on total cost, or more importantly, as Simmons and Nelson point out in their article, on quality, nurses have a tremendous impact on patient care-the core business of health care organizations. Simmons and Nelson address an important issue concerning nurses-their health. Very simply, if nurses are to provide the best service, they must be healthy, and stress has a strong and demonstrated impact on health. Combine this with the fact that nursing is one of the most stressful occupations, and it becomes clear that stress will have an impact on cost and quality. In their study of eustress (understood as the antithesis of distress), the authors conclude that a conceptual shift needs to occur from prevention of distress to the generation of eustress. By demonstrating a link between hope and the state of active engagement in work associated with eustress, the authors suggest an approach that echoes the burgeoning literature on spirituality and business: Make it possible for people to engage fully in their work and workplace.

The article by David Ketchen, Timothy Palmer, and Larry Gamm, "The Role of Performance Referents in Health Services Organizations," moves our attention from human resources to strategy. This article examines the use of performance referents by health care executives, and considers the effects of selection on strategic choices and performance. The notion of who is selected is particularly intriguing given the nature of the health care environment. Many people have observed that health care organizations operate in an institutional environment where mimetic forces are critical-what other health care organizations do creates pressure to do the same. As one health care executive put it, once a certain high-prestige hospital adopted a new practice, it was harder to convince her own board not to do it than to do it. There is an ongoing theoretical debate about how much agency individual organizations actually have in institutional environments. This article has the potential to provide insight into the nature of agency in the face of mimetic pressures to conform. On the one hand, mimetic pressures are very real. On the other hand, this article suggests that health care organizations can choose their referents. Ketchen and his coauthors also consider the impact of the choice of referents on performance. We hope that the authors will choose to continue this research by examining empirically both what drives the choice of referents and what impact that choice has on how performance is evaluated.

As an example of the necessity of finding appropriate referents, Ketchen et al. use the example of rural hospitals that may find it more useful to compare their performance with one another than with larger facilities in urban areas. The article by Margarete Drain, Lynn Godkin, and Sean Valentine, "Examining Closure Rates of Rural Hospitals: An Assessment of a Strategic Taxonomy," demonstrates the necessity for careful comparisons. They provide a model that hospital executives can use to assess key internal areas that affect rural health organizations. The high closure rate of rural hospital facilities was the driving force behind the study. They argue that rural hospitals have unique aspects, and that these are critical to understanding the factors that influence survivability.

We echo Drain and her colleagues' assertion that rural health services justify separate investigations. In a future issue we will have a special FORUM on rural health. John Kralewski from the University of Minnesota School of Public Health and a member of the Journal's editorial board will be the Guest Editor. This FORUM will provide an opportunity to explore, among others, some of the organizational and environmental challenges that Drain et al. have identified.

-Barbara Bigelow

Coeditor

-Margarete Arndt

Coeditor