Nursing Entrepreneurship

Saturday, 7 November 2015

Brenda L. Smith, BScN, BA, OHNdpl, RN
School of Nursing - MSN program, Trinity Western University, Langley, BC, Canada

Nursing entrepreneurship presents as a viable and attractive approach for nursing practice that serves to reinstate professional autonomy, advance nursing professionalism, and to participate in health system transformation.  And yet, in countries such as Canada where universal healthcare funding has most nurses working as employees for state-funded health service providers, few nurses are self-employed.  This thesis sets out to explore the possible contributions of nurse entrepreneurship in Canada.

According to the International Council of Nurses (ICN, 2004),  nursing entrepreneurship reflects a return to nursing’s traditional right to independent practice while engendering professional empowerment and health care transformation.  During the late 19th and early 20th century, the majority of Canadian graduate nurses practiced independently as private duty nurses (McPherson, 1996).  Private duty nurses were responsible for acquiring their own patient cases and defining the conditions of their work in relation to their patient’s health care needs.  Remuneration for nursing services came directly from the patient or the patient’s family and nursing care was usually delivered within the patient’s home or the hospital, as a form of supplementary care (McPherson, 1996; Whelan, 2012).  The private duty nurse assumed complete care of the patient while enjoying a high level of professional autonomy (Whelan, 2012). 

Following World War II, substantial recurrent government funding was made available for hospital capital and operating costs and the supply of private duty nurses could no longer meet the service demands of the growing number of medical institutions (McPherson, 1996, Whelan, 2012).  Eventually, hospital administrations abandoned private duty nursing, opting to hire registered nurses in staff positions that were institutionally controlled and under physicians’ authority (McPherson, 1996; Wall, 2013b; Whelan, 2012).  During the late 20th century, administration of the Canadian public health system assumed an efficiency-focused approach (Armstrong & Armstrong, 2008; Wall, 2013a).  Today, nurses are increasingly required to participate in corporate interests that support an agenda of efficiency rather than the provision of care that is congruent with the profession’s values (Wall, 2013a).

Nursing entrepreneurship - often termed private practice, independent practice, independent contractor, and self-employed practice – sees the nurse as “a proprietor of a business that offers nursing services of a direct care, educational, research, administrative or consultative nature.  The self-employed nurse is directly accountable to the client, to whom, or on behalf of whom, nursing services are provided” (ICN, 2004, p.4).  It is important to note the distinction between nurse entrepreneur and advanced practice nurse (APN) i.e. nurse practitioners, nurse midwives, clinical nurse specialists and nurse anesthetists. The International Council of Nurses (2003) asserts that nurse entrepreneurs are not necessarily APNs and the majority of APNs are not entrepreneurs.

Within nursing scholarship, there is a paucity of research regarding contemporary nursing entrepreneurship performed by registered nurses.  In Canada, as with many other countries with universal healthcare funding, the literature predominantly consists of anecdotal, motivational, or editorial narratives.  Wall (2014, 2013a; 2013b) conducted a qualitative inquiry using focused ethnography to study 20 nurses in independent practice within a western Canadian province.  From the data, Wall extracted themes that relate to the innovative possibilities of nurse entrepreneurs as change agents in the quest for professional advancement and health system transformation. 

Wilson, Averis, and Walsh (2003) surveyed 54 private practice nurses in Australia (with a similar health system) using a two-round Delphi technique to ascertain the reasons for nurses going into business and their respective experiences associated with being entrepreneurs.  In addition to compiling a list of the various independent nursing practices, common influences for pursuing nursing entrepreneurship such as professional autonomy and barriers to practice such as lack of remuneration, a viable referral system, and recognition of their respective nursing services were identified. 

Drennan et al., (2007) conducted an integrative review to investigate the scope of entrepreneurial practice assumed by nurses, midwives and health visitors in the United Kingdom and the factors influencing this mode of practice.  From the integrative review, only three empirical studies emerged.  These studies explored the experiences of nurse entrepreneurs and revealed findings similar to those of Wilson et al. (2003). 

The grey literature is largely comprised of a handful of dissertations related to nursing entrepreneurship along with professional practice guidelines and handbooks for the self-employed nurse published by various provincial, national and global nursing organizations, interest groups, and regulatory bodies.  Overall, the research supports the common anecdotal evidence and motivational literature that identifies nursing entrepreneurship as an opportunity for the advancement of professional nursing practice while meeting the needs of clients that otherwise risk falling into gaps present within the current health system (Wall, 2014; Wall, 2013a; Wall, 2013b; Wilson, Whitaker & Whitford, 2012).  Likewise, national and global nursing organizations encourage nurses to engage in health system transformation that seeks to broaden health care beyond hospitals and other institutional settings while ensuring nurses work to their full scope of practice (CNA, 2012; ICN, 2004).  In departing from the organizational constraints that serve to erode nursing professionalism, nursing entrepreneurship affords a level of professional autonomy that supports and exemplifies the profession’s values and goals (Wall, 2013a).  Global estimates indicate that approximately 0.5% - 1% of working nurses are nurse entrepreneurs (ICN, 2004).  No readily available statistics specific to self-employed nurses in Canada were identified as their numbers are often embedded within the generic category “other” which often captures employed nurses in practice areas such as education, research, occupational health, and private insurance companies.  Practicing along the margins of the profession, it is surmised that the number of self-employed nurses in Canada likely reflects the global experience (Wall, 2013a).  So, why the limited uptake?

Using an interpretive description approach, the aim of this qualitative study is to acquire the perspectives of practicing Canadian nurse entrepreneurs to guide the development of national and provincial policies that support nursing entrepreneurship.  In conjunction with these perspectives, national nurse leaders will be recruited to participate in qualitative interviews regarding policy formation strategies that seek to promote the expansion of nursing entrepreneurship in Canada.

A research approach specifically developed to reflect a nursing orientation, interpretive description (ID) is a qualitative methodology that seeks to describe and interpret a phenomenon through the lens of those who live it (Thorne, Reimer-Kirkham & MacDonald-Emes, 1997).  Thorne et al. (1997) stress that ID “ought to be located within the existing knowledge so that findings can be constructed on the basis of thoughtful linkages to the work of others in the field” (p. 173).  Through the use of a scaffolding metaphor, Thorne (2008) emphasizes the significance of establishing a solid platform to guide the research investigation.  In the case of nursing entrepreneurship, the scholarly literature, although very sparse, reflects common findings.  Themes related to nursing professionalism, autonomy, and the provision of nursing care that reflects the values embraced by the profession are woven throughout the literature identified.  Also common within the literature, is the need for viable client referral and remuneration systems for nursing entrepreneurs and institution of public credibility. 

From this platform, further investigation is warranted regarding the experience of nurse entrepreneurs to illuminate current economic, political and legislative factors that impact the uptake of nursing entrepreneurship in Canada. Seeking to draw upon the expertise of this unique form of practice, a purposive sample consisting of 8-12 nurse entrepreneurs from across Canada will be invited to participate in telephone or in-person interviews.  Participants will be practicing self-employed nurses with a minimum of two years of self-employment experience.  This investigation will comprise the first stage of this two-stage research project.  As interpretive description “responds to the imperative of informed action” (Thorne, 2008, p. 26), 4-6 national nurse leaders will be invited to explore policy formation strategies using the findings from stage one with the intent to increase uptake of nursing entrepreneurship within Canada. 

Thematic analysis will be employed to develop a composite picture of nurse entrepreneurship in Canada and corresponding policy formation strategies.  Interviews will be audio recorded and transcribed verbatim.  Data will be coded using a dynamic process, providing the opportunity to consider the data from multiple “angles of vision” (Thorne, 2008, p. 147).  This poster will introduce nursing entrepreneurship as a means of effecting professional advancement and health system transformation.  An interim report on preliminary findings and possible implications for future policy formation will be included.

In conclusion, nursing entrepreneurship can serve to advance professional nursing practice while meeting the needs of nursing clients that otherwise risk falling into health system gaps.  As gaps within the public health system continue to widen in the pursuit of efficiencies, more entrepreneurial opportunities for health care delivery services will likely arise.  If registered nurses do not position themselves as entrepreneurs, this work will be assumed by others whose primary objective may not include the provision of safe, ethical, effective health care.  Engagement in policy formation is essential for nursing entrepreneurs to establish public credibility and legitimate recognition by provincial and national nursing associations and regulatory bodies for this innovative form of nursing practice.