Anne Wilson, PhD, MN, BN, FRCNA
Nancy Whitaker, BPsych (Hon)
Deirdre Whitford, PhD
Health reform worldwide is required due to the largely aging population, increase in chronic diseases, and rising costs. To meet these needs, nurses are being encouraged to practice to the full extent of their skills and take significant leadership roles in health policy, planning, and provision. This can involve entrepreneurial or intrapreneurial roles. Although nurses form the largest group of health professionals, they are frequently restricted in their scope of practice. Nurses can help to improve health services in a cost effective way, but to do so, they must be seen as equal partners in health service provision. This article provides a global perspective on evolving nursing roles for innovation in health care. A historical overview of entrepreneurship and intrapreneurship is offered. Included also is discussion of a social entrepreneurship approach for nursing, settings for nurse entre/intrapreneurship, and implications for research and practice.
Citation: Wilson, A., Whitaker, N., Whitford, D. (May 31, 2012) "Rising to the Challenge of Health Care Reform with Entrepreneurial and Intrapreneurial Nursing Initiatives" OJIN: The Online Journal of Issues in Nursing Vol. 17, No. 2, Manuscript 5.
Key words: nursing, nursing role, entrepreneurial, intrapreneurial, social entrepreneurship, Future of Nursing, health reform
Pressure continues to mount as health systems worldwide endeavour to meet the needs of the population efficiently, economically, and effectively. There are widespread concerns about inappropriate skill mixes in the health workforce, difficulty recruiting and retaining staff, as well as the underutilisation of some health professionals (of which nursing is one). Needs-based, patient-centred approaches to care that employ mixed workforce teams are widely advocated as essential for health care systems to provide seamless, affordable, and quality care that is accessible to all. This approach to health care, specifically the utilization of evidence based interventions, has demonstrated improved health outcomes (McDermott, Tulip, & Schmidt, 2004; Rittenhouse et al., 2010). Interdisciplinary healthcare teams have the potential to improve outcomes, subsequently reduce costs and increase timely access to care (Willens, Cripps, Wilson, Wolff, & Rothman, 2011). A health infrastructure that is adequately funded delivers relevant care and is supported by a workforce suited to the population’s health care needs is, therefore, essential to the delivery of high quality care.
...the unique skills held by generalist and specialist nurses are often underutilised across the health continuum. Nurses comprise the largest proportion, up to 80% (Hughes, 2006), of the health workforce and are considered to be the front line staff across the health continuum in most health services and countries. In spite of the immense and significant role that nurses play in the health care system, they are seldom considered equal partners in multidisciplinary health care teams. As a result, the unique skills held by generalist and specialist nurses are often underutilised across the health continuum. However, the long-awaited and recently released report from the Institute of Medicine (IOM) (2010) Robert Wood Johnson Foundation Initiative entitled, The Future of Nursing: Leading Change, Advancing Health (FON), indicated that nurses have an important contribution to make in “...building a health care system that will meet the demand for safe, quality, patient-centred, accessible, and affordable care” (Institute of Medicine, 2010, p.1) . However, in order to deliver these outcomes, it is essential for nurses to practice to the full extent of their knowledge and training while transforming the way in which health care is provided by entering into full partnerships with other health care professionals.
Indeed, research has recognised that there is unrealized scope for extended practice for nurses working in multidisciplinary teams with doctors and allied health professionals (Buchan & Dal Poz, 2002). It is due to this acknowledgement that in the past two decades nurses’ scope of practice has broadened considerably with the development and implementation of advanced and specialist nursing roles, such as that of the nurse practitioner and the advanced practice nurse, implemented through new models of practice. These expanded roles have been implemented in multiple care settings across the continuum of care from community or public health services and primary care, to acute care, and supportive or long-term care.
In this article, we will discuss how emerging and evolving entrepreneurial and intrapreneurial roles in nursing are rising to meet the challenge of health care reforms throughout the globe, across the continuum of health care. A historical overview of entrepreneurship and intrapreneurship is offered. We offer social entrepreneurship as a sustainable model of enterprising nurse-directed health care and describe brief examples of settings for nurse entre/intrapreneurship, and implications for research and practice.
Innovation in Health Care
The need for nurses to seek unique roles that support a wide scope of practice and which fulfil gaps in health care is recognised in the Institute of Medicine report. Innovations in health care directed towards improved health outcomes, diagnostic and treatment options, as well as the efficiency and cost effectiveness of the healthcare system are frequently considered the result of information technology rather than human factors. The need for nurses to seek unique roles that support a wide scope of practice and which fulfil gaps in health care is recognised in the Institute of Medicine (2010) report. Innovative and creative health care provided by entrepreneurial and intrapreneurial nurses across all health settings is one way of expanding the human influence of innovative health care.
Entrepreneurship in Nursing
Nursing entrepreneurship provides nurses with self-employment opportunities which allow them to pursue their personal vision and passion to improve health outcomes using innovative approaches. Similar to other entrepreneurs, a nurse entrepreneur is considered to be a “proprietor of a business that offers nursing services of a direct care, educational, research, administrative or consultative nature” (International Council of Nurses, 2004, p.4). As such, the nurse is self-employed and is directly accountable to the client (e.g., individual, private, or public organisation) for whom they provide services (Liu & D'Aunno, 2011). Such nurses may conduct an independent clinical practice; own a business (e.g., nursing home or pharmaceutical company); or run a consultancy business in, for example, education or research. Thus, nurse entrepreneurs are innovators who initiate incentives that lead to change, the modernisation of health systems, and demonstration of leadership (Raine, 2003).
Use of creativity to develop a new idea, improve service or delivery methods, or develop new products or new ways to use existing products is a fundamental characteristic of entrepreneurship. Use of creativity to develop a new idea, improve service or delivery methods, or develop new products or new ways to use existing products is a fundamental characteristic of entrepreneurship. Combining these characteristics with advanced or specialist skills and knowledge, at the very least, entrepreneurial nurses are advanced practice nurses who create products or services which they can market to external sources.
Intrapreneurship in Nursing
In contrast to an entrepreneur, a nurse intrapreneur is a salaried employee, often of a government run health service, who develops, promotes, and delivers an innovative health or nursing service within a health care setting, such as hospital or nurse-led clinic (Hewison & Badger, 2006). Nurses have been developing intrapreneurial ventures since the time of Florence Nightingale; however, it is only now with increasing demand for safe, high-quality, and effective health care services that more resources are dedicated to nurses assuming a wider variety of roles with more responsibility.
...a nurse intrapreneur is a salaried employee, often of a government run health service, who develops, promotes, and delivers an innovative health or nursing service within a health care setting, such as hospital or nurse-led clinic. Nurse intrapreneurs develop innovative health practices from within the organisational framework in which they work, and consequently share the risks and benefits associated with this innovative practice with their employer (Dayhoff & Moore, 2005). The type of innovations developed by intrapreneurs often involve efforts to transform workplace climate or culture, improve processes, or develop new products or services (Drucker, 1985). Intrapreneurs are often motivated by the needs of their patients to identify gaps in service that can be addressed through the determined work of a health care team that may or may not include themselves.
...entre/intrapreneurial nurses will generally operate at an advanced level due to the application of a highly developed set of knowledge and skills. Although defined by the context of how they practice, rather than the position they hold, entre/intrapreneurial nurses will generally operate at an advanced level due to the application of a highly developed set of knowledge and skills. There are several personality characteristics shared by both entre- and intrapreneurial nurses. These include self-confidence, courage, integrity, self-discipline, and the ability to take risks, deal with failure, and articulate their goals (Cooper, 2005; Wilson & Averis, 2002). A conceptual model depicting the salient characteristics of the nurse entrepreneur (Wilson & Averis, 2002), including internal and external influences, advantages, and challenges, may be similarly applied to the nurse intrapreneur within the employed setting. It is essential to both entre and intrapreneurial ventures that the nurses are able to seize opportunities to address gaps in service provision; are provided the infrastructure support to do so; and are able to explain what they are doing, why they are doing it, and how service should be provided in the future (Cooper, 2005).
...entre- and intrapreneurship is defined differently across professions and countries.Due to a variety of factors, it is difficult to determine how many nurses are working in entre and intrapreneurial roles throughout the world. For instance, entre- and intrapreneurship is defined differently across professions and countries. Thus the concept of nurses as entrepreneurial may not be widely understood or realised in some areas/cultures.
Nurse entrepreneurs may work as independent contractors and it is often difficult to systematically record the number of nurses outside of the public and private systems by role and skill mix. In some regions, demographics may not exist. In addition, some countries may not recognise independent nurses, who own and run their own primary health practices, to be nurses at all (Manion, 1991).
Figures gathered by the International Council of Nurses estimated that 0.5-1% of registered nurses worldwide work in entrepreneurial roles. Actual numbers within individual countries may be lower or higher as estimates of nurses or midwives who are self-employed or own professionally related businesses are as low as approximately 0.1% in New Zealand (Drennan et al., 2007) and 0.18% in the United States (Cheater, 2010) and as high as 18% in the United Kingdom. However, it appears more common for midwives to be self-employed with estimates of 50% self-employed in New Zealand and 64% in the Netherlands. In Australia, numbers are unknown as the most recent Australian Institute of Health Workforce Nursing and Midwifery Labour Force Survey (2009) does not mention self-employed nurses, although numbers are generally thought to be low. Better data collection and information infrastructure is required for targeted health workforce planning and this need is evident worldwide (Institute of Medicine, 2010).
Historical Overview of Entrepreneurship and Intrapreneurship
Historically, there have been challenges and barriers to entre- and intrapreneurship initiatives by nurses. However, the emphasis on healthcare reform has supported this evolving nursing role, and some progress has been made.
The need for healthcare reform globally remains a priority. Nevertheless, the largest group of health providers – the nursing and midwifery workforce – is, on a global level, understaffed, undertrained, and poorly deployed (World Health Organization, 2010). Nursing’s scope encompasses:
...autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. It includes the promotion of health, the prevention of illness, and the care of ill, disabled and dying people. (World Health Organisation, 2010, p. 55).
Consequently, nurses are well able to be frontline service providers acting both as individuals and as members and coordinators of interprofessional teams. In spite of the breadth of services provided by nurses, nursing insight into health needs across the continuum, and recognition that nurses and miwives are pivotal to health services, nurses and midwives are not often identified as key stakeholders in the development of health policy. In addition, they are frequently not equal partners on health teams.
Barriers to Self-Employment
For nurses to be full partners with other health professionals, ignorance and confusion about their role and relationship with other care providers, fiscal issues affecting fee setting and client reimbursement, and legal issues need to be addressed. For nurses to be full partners with other health professionals, ignorance and confusion about their role and relationship with other care providers, fiscal issues affecting fee setting and client reimbursement, and legal issues need to be addressed (Caffrey, 2005; Wilson, Averis, & Walsh, 2004). Studies undertaken in 2002 (Wilson & Averis, 2002), and 2004 (Wilson, et al., 2004) indicated that research into entrepreneurial nursing remains limited and insufficient to inform changes to health policy and nurse education.
Barriers to self-employment for nurses remain. Lack of recognition such as that afforded to other self-employed health service providers continues along with professional isolation, lack of a safety net, and resistance or hostility from colleagues. In addition to the previously mentioned absence of reliable figures on the number of nurses working in entre/intrapreneurial roles, there is also a lack of research to support changes to the health system required to take full advantage of nurses working in these roles. Specifically, there has been little research to provide practical guides for health systems worldwide to implement innovative nursing roles successfully as nurses in entre- or intrapreneurial roles often face barriers to effective practice. There is also a lack of research findings to inform changes to nursing education so that nurses may envision and pursue such roles.
Healthcare Reform and the Future of Nursing
In 2008, a major initiative began with the intention to assess and transform the nursing profession as the United States health care system underwent major changes. A two-year project was launched by the Robert Wood Johnson Foundation (RWJF) with the Institute of Medicine with the intent to release a report that would make recommendations for an action-oriented plan for the future of nursing (Institute of Medicine, 2010).
The Future of Nursing report identified that nurses, working at the forefront of patient care, can play a vital role in helping to realize objectives to make health care accessible, acceptable, and affordable. Before this can occur, barriers to prevent nurses from responding effectively to rapidly changing health care settings and an evolving health care system need to be addressed. Then nurses will be even better positioned to lead change and advance health (Institute of Medicine, 2010). Barriers include nurses’ inability to practice to their full extent, lack of access to an education system that allows for seamless progression to higher levels, and lack of opportunity for full partnership with other healthcare professionals. Other needs are improved research, better data collection, and information infrastructure on health care workforce requirements.
Historically, innovation and entrepreneurship in nurse education have been avoided because dominant values are acceptance, standardisation, and prescription. Historically, innovation and entrepreneurship in nurse education have been avoided because dominant values are acceptance, standardisation, and prescription (Robinson, 2008). Directed recruitment and education strategies are needed to prepare nurses for entre/intrapreneurial roles to provide leadership, co-ordinate care, and establish multi-disciplinary pathways. This is true not just in the United States, where the FON report was generated, but worldwide. There are risks and barriers in being innovative and a leader. But, for nurses to gain an equal place both in the workplace (and around the policy table), they need to be encouraged to be confident in their skills (Liu & D'Aunno, 2011).
Progress to Date
A collaborative environment to capitalize on entrepreneurial skills of advanced practice and specialist nurses is required for health planners and nurses to realize their vision (Austin, Luker, & Roland, 2006). Some progress has been made to date, but not without continued challenges.
In the United States, nurse practitioners (NPs) have directed nurse-managed health centres (NMHC) in locations that are medically underserved to provide a safety net for Medicaid recipients and uninsured citizens (Hansen-Turton, Bailey, Torres, & Ritter, 2010). In these centres, NPs provide high quality and cost effective care which has been found to encourage higher rates of generic medication fills and lower rates of hospitalisation (Hansen-Turton, Line, O’Connell, Rothman, & Lauby, 2004). These services have high patient satisfaction scores, as is common for many NP-managed primary health services.
However, it can be difficult for this type of nurse-led service to attain financial sustainability as they rely on Medicaid and Medicare reimbursement, private grants, and government funding. Most of these NMHCs are operated by nursing schools and some receive funding from these parent organisations. This can limit the level of funding the centres receive from the federal government. In addition to this difficulty, 48% of managed care insurers do not reimburse NPs providing primary care (an illegal practice); however, this law continues to go unenforced (Hansen-Turton et al., 2010). The final hurdle faced by these NP-led primary healthcare services is primary care physicians' associations working to define sole primary care providers as physicians only. Resistance from medical associations to nurse-led services is not uncommon and needs to be addressed for effective health reform that features nurses in full scope, innovative roles, such as the entrepreneurial NMHCs above, to succeed.
A Social Entrepreneurship Approach for Nursing
Social entrepreneurship is an approach that involves the design and implementation of innovative ideas and practical models for achieving a social good. Social entrepreneurship is one approach that is well-suited to nurse entrepreneurs and may increase such opportunities within the profession. While most entrepreneurship enterprises are commonly viewed as business ventures intended to achieve financial gain, in nursing, entrepreneurship could be viewed as seeking to achieve good health outcomes for the most number of people. As such, these initiatives represent examples of nurses doing good for the larger society. Social entrepreneurship is an approach that involves the design and implementation of innovative ideas and practical models for achieving a social good (Cheater, 2010; Gilliss, 2011).
In contrast to the traditional business approach of entrepreneurs, a social entrepreneur focuses on creating social returns. Thus, the main aim of social entrepreneurship is to further social and environmental goals. Although social entrepreneurs are most commonly associated with the voluntary and not-for-profit sectors, it need not exclude making a profit (Thompson, 2002). Taking the social entrepreneurship approach in health reform places nurses on a common platform with people who have noticed a need and developed a way of remedying that issue.
If nursing is to build sustainable, nurse-directed, social health models of care that address gaps in health care today, we will be required to demonstrate high impact and effect, which are the data sought by health funders at state and federal levels. Approaching entrepreneurship in nursing from a social heath perspective may enable the innovation and creativity needed for such an impact to be more acceptable within the profession. Furthermore, visibility and articulation of the work of nurse entrepreneurs will hopefully help society begin to understand how long-standing problems and ineffective and/or inefficient models might be addressed in new ways. For example, the United Kingdom High Quality for All review indicated that it was the responsibility of health professionals to lead service improvement initiatives at the local level (Coddington, Sands, Edwards, Kirkpatrick, & Chen, 2011). As a result of this report, primary care trust boards are now required to consider proposals from National Health Service (NHS) staff on how to improve services locally through the creation of social enterprises.
Settings for Nurse Entre/Intrapreneurship
Three paradigms encompass the health care services provided across the continuum of care. These are generally referred to primary, secondary, and tertiary care. An arrangement of preventive public health services, primary care outpatient clinics, local general hospitals, and regional hospitals with intensive and specialty care units is embedded in the array of services. Within each of these health care sectors, there are a range of services available both internally and, to a lesser extent, externally to address community health and wellness needs.
Although many individuals access these services in one setting, there are few populations which benefit from care across the three settings in a short period of time. Older persons often suffer from co-morbid and chronic illnesses and therefore require access to services across this continuum of care. These services may often be initially delivered through home health agencies, followed by assisted living, and then care in a skilled nursing facility as the patient’s health declines. Theoretically, consumers enter care at the lowest level capable of addressing their problem(s) and then advance to higher levels only as their care becomes more complex. In practice, the services may overlap, especially primary and secondary care settings, and this patients may access care in a more circular fashion depending on need for services.
Intra/entrepreneurial nursing may occur at any point in partnership or separately. Due to factors such as financial, geographical, and cultural barriers to accessing care and lack of information to assist consumers to make healthcare choices, the continuum of care is a theoretical model rather than an actual system of care delivery. The model depicted in Figure 1 can be used to describe how a patient may theoretically move through the health care system or enter and exit the system at any given point. It is helpful to illustrate the many opportunities and variety of settings for entre/intrapreneurial roles. Intra/entrepreneurial nursing may occur at any point in partnership or separately. Below, we offer some examples of how nurse entrepreneurs and intrapreneurs are providing care across the continuum at each of the three levels of care.
Nurses play a vital role throughout the continuum of care and work in both entrepreneurial and intrapreneurial roles to serve the primary care needs of the community. In the context of global population aging, with increasing numbers of older adults at greater risk of chronic, non-communicable diseases, rapidly increasing demand for primary care services is expected around the world. This is true in both developed and developing countries. The World Health Organization (2000) cites the provision of essential primary care as an integral component of an inclusive primary health care. New ways to address old problems are needed.
In primary care, intrapreneurial nurses work in the local community as a first point of consultation, providing routine health screening, preventive care, and health education to avoid the occurrence of disease. Nurses in this setting often also provide care for stable patients suffering from common chronic illnesses such as hypertension, diabetes, asthma, chronic obstructive pulmonary disease (COPD), depression and anxiety, back pain, arthritis, and thyroid dysfunction (Campbell, 2009). Primary care also includes many basic maternal and child health care services such as family planning services and immunisation. In primary care, nurses with advanced or specialist qualifications often provide care through nurse-led community health clinics.
Nurse intrapreneurs have been involved in producing more effective primary care through programs such as that developed by Mary Naylor and Karen Buhler-Wilkersen (University of Pennsylvania School of Nursing) who developed an innovative program for improving elder care in their community. These intrapreneurs established a community-based practice employing advanced practice nurses to offer functional support and multidisciplinary services for older persons with co-morbidities. The program allows elderly people to remain in their homes rather than be forced to enter residential care facilities. Naylor and Buhler-Wilkerson (1999) said,
...if we are successful in realizing our dreams through LIFE, we will have articulated a concept for community-based care for the new millennium that embraces the leadership of nurses in offering innovative and practical solutions to the complex needs of high-risk, vulnerable persons and their families (Naylor & Buhler-Wilkerson, 1999, p.127).
Indeed, recent literature indicates that this program has, and continues to be, a highly effective, cost efficient, sustainable, and essential enterprise (The University of Pennsylvania, 2008). The success of this program is indicative of the power that intra- and socially entrepreneurial nurses have in building and sustaining primary care services.
The effectiveness of intra/entrepreneurial nurses working in primary care has been demonstrated in studies which found that 93 to 100% of clients were completely or very satisfied with the quality of care provided (Coddington, et al., 2011; Morales-Asencio et al., 2008) . For example, an entrepreneurial nurse-managed paediatric clinic enabled clients to develop therapeutic relationships with the nurse practitioners, removed barriers to care such as transportation by providing regional services, and improved healthcare access (Coddington, et al., 2011).
The introduction of entre- and intrapreneurial roles into the primary care setting is expected to result in even more timely access to services. The introduction of entre- and intrapreneurial roles into the primary care setting is expected to result in even more timely access to services. This will thereby increase the efficency and economy of this first step in the health care system and subsequently reduce pressure on the system at higher leves of care. These outcomes will result from an expanded scope of nursing practice in this setting, so that entrepreneurs and intrapreneurs can take on duties previously in the domain of doctors only. It is also believed that nurses working in this way may remove the demarcation between professional groups, thus promoting equal partnerships among health providers from various disciplines (Traynor et al., 2008).
...nurses working in this way may remove the demarcation between professional groups, thus promoting equal partnerships among health providers from various disciplines. One way that health care reform efforts in multiple countries are moving toward this goal is through the introduction of nurse practitioners to expand the primary care workforce. These initiatives have been recognised as a feasible and effective solution to ease the shortage of primary care physicians in many countries. However, the productivity and cost-efficiency of NPs is dependent on several factors, including length of consultations and patient load (Browne & Tarlier, 2008). An additional consideration is that patients report more satisfaction with using primary care practice settings than secondary care services (e.g., accident and emergency) to treat non-life threatening conditions (Hutchison, 2003).
Secondary care may be provided in the community or in a hospital and similar settings. The focus of this care is typically treatment for short-term acute illnesses, injury, or other health conditions in order to diagnose and treat disease in the early stages before it causes morbidity. Growth in the secondary care sector is noted due to the increased rate of presentation to emergency departments for patients who bypass primary care (often vulnerable populations such as those without insurance coverage) and overload problems in tertiary care (Harris, Patel, & Bowen, 2011; Hull et al., 2000).
Nurse intrapreneurs work within hospitals to improve the services provided and inform future direction for improvements to hospital policy and training. Nurse intrapreneurs work within hospitals to improve the services provided and inform future direction for improvements to hospital policy and training. Intrapreneurs working in secondary care have conducted successful programs such as nurse triage in emergency department for psychiatric patients (Happell, Summers, & Pinikahana, 2002). Case finding is performed using a simple screening assessment completed by the primary or triage nurse followed by an in-depth interview by a geriatric clinical nurse specialist. Patients with unmet medical, social, or health needs are referred to their primary physicians, to outpatient geriatric evaluation and management centres, or to community agencies (Mion, 2001).
The effectiveness and feasibility of intrapreneurial nurse practitioners in conducting clinics such as those for minor injuries in emergency departments is well documented (Wilson & Shifaza, 2008; Wilson, Zwart, Everett, & Kernick, 2009). A developing area of secondary care in Australia is the General Practice (GP) Plus and Super clinics which are located in large communities and provide both primary and secondary services with access to allied health teams, nurse practitioners, general practitioners medical specialists, imaging, and dental care.
Another innovation is the introduction of entrepreneurial ‘Smart Clinics’ or privately funded stand-alone nurse practitioner-led clinics in Australia (SmartClinics, 2010). These clinics offer an increased connection to everyday care by locating in easy to access locations and operating outside normal business hours. Every Smart Clinic NP holds a Masters of Nursing degree, nurse practitioner endorsement, and is registered with the Australian Health Practitioner Regulation Agency. The care patients receive at Smart Clinics is purportedly underpinned by current evidence-based clinical guidelines, all of which are defined by their Chief Medical Officer. The Smart Clinics advertise that they provide personalised, patient centred care (SmartClinics, 2010).
A private nurse-led community health clinic established in Melbourne, Australia accepts referrals from hospitals and allied health professionals and provides chronic disease management, preventive health care, risk identification, wound care, medication administration, carer support, and advice (Campbell, 2009). Positive feedback is received from GPs in the area; however, the nurses are limited by lack of Medicare item numbers and therefore are unable to bulk bill or charge rates similar to those charged by other health professionals.
Tertiary care is specialized consultative health care, usually for inpatients in a facility such as an acute hospital that has personnel and facilities for advanced medical investigation and treatment. Methods of care focus on reducing the negative impact of disease by restoring function and reducing related complications. Patients are frequently referred from a primary or secondary level health professional and may be discharged to them for follow-up care. Nurses in tertiary care generally do not have first contact with patients, and services may include cardiology clinics, urology, oncology, and burn treatment, and elder care facilities (Caffrey, 2005; Schadewaldt & Schultz, 2011).
A systematic review summarising the evidence of seven randomised controlled trials reported that, although there were no harmful effects identified in patients with coronary heart disease exposed to a nurse-led clinic, inconsistencies in the interventions used made comparison difficult (Schadewaldt & Schultz, 2011). The major intervention consisted of health education, counselling behaviour change, and promotion of a healthy lifestyle. Although a few risk factors were significantly reduced in the short term by attending nurse-led clinics, long-term changes were less apparent, possibly because the success of modifying behaviour such as smoking cessation and diet adherence was limited.
However, intrapreneurial nurse-led services may positively influence perceived quality of life and general health status for this population. In order to deliver the healthcare needed by consumers with both complex and simple needs, it is essential to have healthcare professionals available to assist with transition between and across the levels of care. Nurses are working to meet this need through the development of innovative, entrepreneurial and intrapreneurial roles at all of these care levels. To provide services that meet individuals’ needs, and are equitable and economical, both of these approaches are required (Hewison & Badger, 2006).
One issue for intrapreneurial nurses working within an organization where tertiary care is provided is dealing with a hierarchy in which doctors are over represented in policy formation and senior management positions. One issue for intrapreneurial nurses working within an organization where tertiary care is provided is dealing with a hierarchy in which doctors are over represented in policy formation and senior management positions. This often discourages nurses challenging physician practice and may deny them the ability to openly question decisions when they have a concern. (Churchman & Doherty, 2010). This culture prevents innovation because innovators’ suggestions for change tend to be dismissed.
These examples of nurse entre- and intrapreneurs working in primary, secondary, and tertiary care demonstrate potential benefits to patients and the variety of settings for nurse entre/intrapreneurs. Patients value the problem solving approach and advocacy that nurses provide, while nurses feel support for their care and enjoy providing continuity of care (Caffrey, 2005). Our findings indicated that there was no greater risk of poorer outcomes in the nurse-led clinics, although the effectiveness of clinics might be dependent on the intensity of the nursing support. From the literature reviewed it is evident that the combination of counseling and regular assessment of risk factors and health status delivered at nurse-led clinics is supported by the available research. Given that outcomes were, in general, equivalent between nurse-led (i.e., nurse entre- or intrapreneurs) and other type clinics, it would be beneficial for further research to investigate the cost-effectiveness of the different models of care.
Implications for Research and Practice
Health reform worldwide is needed due to the substantial aging population and increase in chronic diseases (e.g., diabetes, asthma). To meet future needs, we must enable nurses to practice to the full extent of their skills. Nurses can help to improve health services in a cost effective way, but to do so, they must be perceived as equal partners in health service provision.
Some nurses are already working in entre- and intrapreneurial roles which demonstrate the positive outcomes that can be achieved when nurses meet their full potential. These nurses are working across the continuum of care. Some nurses are already working in entre- and intrapreneurial roles which demonstrate the positive outcomes that can be achieved when nurses meet their full potential. These nurses are working across the continuum of care. It seems obvious that entrepreneurial nursing roles are forging the way for this type of partnership by examples of nurses conducting clinics in primary and secondary care and as specialists to manage exacerbations of chronic illness in tertiary care settings.
Nurse intrapreneurs are, to a lesser extent, also being recognised as partners. Research on nurse-led initiatives within hospitals in particular is limited. Research that confirms the importance of these roles to provide improved health outcomes and to inform how this may be achieved practically is required.
We recommend several actions or strategies to promote entre- and intrapreneurship in nursing. These may include:
- Nurse education that includes placement with a nurse entrepreneur and/or a business course to ensure that graduating nurses learn skills to lead, challenge, and be innovative.
- Interdisciplinary learning so that allied health and medical professionals are introduced to the concept of nurses as equal partners in health care.
- Greater opportunities of shared inter-disciplinary collaboration in research, education, and practice to foster cohesion and role familiarity amongst health professionals.
Health reform is increasingly targeted towards strengthening and expanding primary health systems as care is shifted from hospitals to communities. The renewed emphasis on prevention and health promotion is intended to curb the tide of chronic disease and sustain effective chronic disease management, as well as address health inequities and increase affordable access to services. Given the full potential scope of nurses' practice, the success of health system reforms (such as those in the United States and Australia) depend on a nursing workforce that is appropriately educated and supported for innovative practice roles in multiple settings.
Anne Wilson, PhD, MN, BN, FRCNA
Anne Wilson is an experienced clinician and academic. Anne has a background in primary health care with extensive experience in providing primary health care services in community health, youth, child and maternal health, early intervention, health screening and surveillance. Three significant highlights of her career were establishing a private practice as a nurse entrepreneur, working in the remote Kimberley Ranges of Western Australia and as a community midwife in Scotland.
Nancy Whitaker, BA(Hons), MPsych
Nancy Whitaker received her Bachelor of Psychology (Honours) from Flinders University, Adelaide (Australia). She is now working in the University of Adelaide School of Nursing as a research assistant while studying her Master of Psychology (Clinical), also at the University of Adelaide
Deirdre Whitford, PhD
Deirdre Whitford is an Associate Professor Clinical Practice (Adjunct) for the School of Population Health at the University of Adelaide. Her research and education interests are population and public health, the epidemiology of stroke, the health services workforce, and factors affecting student recruitment to rural and indigenous health setting placements.
Austin, L., Luker, K., & Roland, M. (2006). Clinical nurse specialists as entrepreneurs: Constrained or liberated. Journal of Clinical Nursing, 15(12), 1540-1549.
Browne, A. J., & Tarlier, D. S. (2008). Examining the potential of nurse practitioners from a critical social justice perspective. Nursing Inquiry, 15(2), 83-93.
Buchan, J., & Dal Poz, M. R. (2002). Skill mix in the health care workforce: Reviewing the evidence. Bulletin of the World Health Organization, 80(7), 575-580.
Caffrey, R. A. (2005). Independent community care gerontological nursing: Becoming an entrepreneur. Journal of Gerontological Nursing, 31(8), 12-17.
Campbell, J. (2009). Private nurse clinic. The Australian nursing journal 17(6), 17.
Cheater, F. M. (2010). Improving primary and community health services through nurse-led social enterprise. Quality in Primary Care, 18(1), 5-7.
Churchman, J. J., & Doherty, C. (2010). Nurses' views on challenging doctors' practice in an acute hospital. Nursing Standard, 24(40), 42-48.
Coddington, J., Sands, L., Edwards, N., Kirkpatrick, J., & Chen, S. (2011). Quality of health care provided at a pediatric nurse-managed clinic. Journal of the American Academy of Nurse Practitioners, 23(12), 674-680. doi: 10.1111/j.1745-7599.2011.00657.x
Cooper, M. (2005). Becoming an entrepreneur. Canadian Nurse, 101(4), 14-15.
Dayhoff, N. E., & Moore, P. S. (2005). CNS entrepreneurs: Innovators in patient care. Nurse Practitioner, 6-8.
Drennan, V., Davis, K., Goodman, C., Humphrey, C., Locke, R., Mark, A., ...Traynor, M. (2007). Entrepreneurial nurses and midwives in the United Kingdom: an integrative review. Journal of Advanced Nursing, 60(5), 459-469.
Drucker, P. F. (1985). Innovation and entrepreneurship. Oxford: Butterworth Heinemann.
Gilliss, C. L. (2011). The nurse as social entrepreneur: Revisiting our roots and raising our voices. Nursing Outlook, 59(5), 256-257. doi: 10.1016/j.outlook.2011.07.003
Hansen-Turton, T., Bailey, D. N., Torres, N., & Ritter, A. (2010). Nurse-managed health centers: Key to a healthy future. American Journal of Nursing, 110(9), 23-26.
Hansen-Turton, T., Line, L., O’Connell, M., Rothman, N., & Lauby, J. (2004). The nursing center model of health care for the underserved. Philadelphia. U.S. Centers for Medicare and Medicaid Services.
Happell, B., Summers, M., & Pinikahana, J. (2002). The triage of psychiatric patients in the hospital emergency department: a comparison between emergency department nurses and psychiatric nurse consultants. Accident and Emergency Nursing, 10(2), 65-71. doi: 10.1054/aaen.2001.0336
Harris, M. J., Patel, B., & Bowen, S. (2011). Primary care access and its relationship with emergency department utilisation: An observational, cross-sectional, ecological study. British Journal of General Practice, 61(593), e787-e793. doi: 10.3399/bjgp11X613124
Hewison, A., & Badger, F. (2006). Taking the initiative: Nurse intrapreneurs in the NHS. Nursing Management - UK, 13(3), 14-19.
Hughes, F. (2006). Nurses at the forefront of innovation. International Nursing Review, 53(2), 94-101.
Hull, S., Harvey, C., Sturdy, P., Carter, Y., Naish, J., Pereira, F., ... Parsons, L. (2000). Do practice-based preventive child health services affect the use of hospitals? A cross-sectional study of hospital use by children in east London. British Journal of General Practice, 50(450), 31-36.
Hutchison, B., Ostbye, T., Barnsley, J., Stweart, M., Mathews, M., Campbell, M.K., ... Tyrrell, C. (2003). Patient satisfaction and quality of care in walk-in clinics, family practices and emergency departments: The Ontario Walk-In Clinic study. Canadian Medical Association Journal, 168(8), 977.
Institute of Medicine of the National Academies. (2010). The future of nursing leading change, advancing health. Retrieved from www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx
International Council of Nurses. (2004). Guidelines on the nurse entre/intrapreneur providing nursing service. Geneva, Switzerland.
Liu, N., & D'Aunno, T. (2011). The productivity and cost-efficiency of models for involving nurse practitioners in primary care: A perspective from queueing analysis. Health Services Research,7(2), 594-613. doi: 10.1111/j.1475-6773.2011.01343.x
Manion, J. (1991). Nurse intrapreneurs: The heroes of health care's future. Nursing Outlook, 39(1), 18-20.
McDermott, R. A., Tulip, F., & Schmidt, B. (2004). Diabetes care in remote northern Australian indigenous communities. Medical journal of Australia, 180(10), 512-516.
Mion, L. C., Palmer, R. M., Anetzberger, G. J., & Meldon, S.W. (2001). Establishing a case-finding and referral system for at-risk older individuals in the emergency department setting: The SIGNET model. Journal of the American Geriatrics Society, 49(10), 1379-1386. doi: 10.1046/j.1532-5415.2001.49270.x
Morales-Asencio, J. M., Gonzalo-Jimenez, E., Martin-Santos, F. J., Morilla-Herrera, J. C., Celdraan-Manas, M., Carrasco, A. M., Garcia-arrabal, J. J., & Toral-Lopez, I. (2008). Effectiveness of a nurse-led case management home care model in Primary Health Care. A quasi-experimental, controlled, multi-centre study. BMC Health Services Research, 8(1), 193.
Naylor, M. D., & Buhler-Wilkerson, K. (1999). Creating community-based care for the new millennium. Nursing Outlook, 47(3), 120-127. doi: 10.1016/s0029-6554(99)90006-4
Raine, P. (2003). Promoting breast-feeding in a deprived area: the influence of a peer support initiative. Health & Social Care in the Community, 11(6), 463-469. doi: 10.1046/j.1365-2524.2003.00449.x
Rittenhouse, D. R., Shortell, S. M., Gillies, R. R., Casalino, L. P., Robinson, J. C., McCurdy, R. K., & Siddique, J. (2010). Improving chronic illness care: Findings from a national study of care management processes in large physician practices. Medical Care Research and Review. doi: 10.1177/1077558709353324
Robinson, F. (2008). Nurse entrepreneurs. Practice Nurse, 36(5), 11-12.
Schadewaldt, V., & Schultz, T. (2011). Nurse-led clinics as an effective service for cardiac patients: results from a systematic review. International Journal of Evidence-Based Healthcare, 9(3), 199-214. doi: 10.1111/j.1744-1609.2011.00217.x
SmartClinics (2011). Retreived from www.smartclinics.com.au/
The University of Pennsylvania. (2008). LIFE Reflections. Retrieved from www.nursing.upenn.edu/clinical_practices/Pages/LIFEreflections.aspx
Thompson, J. L. (2002). The world of the social entrepreneur. The International Journal of Public Sector Management, 15(4/5), 413.
Traynor, M., Drennan, V., Goodman, C., Mark, A., Davis, K., Peacock, R., & Banning, M. (2008). 'Nurse entrepreneurs' a case of government rhetoric? Journal of Health Services Research & Policy, 13(1), 13-18.
Willens, D., Cripps, R., Wilson, A., Wolff, K., & Rothman, R. (2011). Interdisciplinary team care for diabetic patients by primary care physicians, advanced practice nurses, and clinical pharmacists. Clinical Diabetes, 29(2), 60-68.
Wilson, A., & Averis, A. (2002). Facets of private practice nursing: A conceptual model. Collegian, 9(2), 16-21.
Wilson, A., Averis, A., & Walsh, K. (2004). The scope of private practice nursing in an Australian sample. Public Health Nursing, 21(5), 488-494. doi: 10.1111/j.0737-1209.2004.021511.x
Wilson, A., & Shifaza, F. (2008). An evaluation of the effectiveness and acceptability of nurse practitioners in an adult emergency department. International Journal of Nursing Practice, 14(2), 149-156. doi: 10.1111/j.1440-172X.2008.00678.x
Wilson, A., Zwart, E., Everett, I., & Kernick, J. (2009). The clinical effectiveness of nurse practitioners' management of minor injuries in an adult emergency department: A systematic review. International Journal of Evidence-Based Healthcare, 7(1), 3-14. doi: 10.1111/j.1744-1609.2009.00121.x
World Health Organisation. (2000). The World Health Report, 2000 – Health systems: improving performance. Geneva: World Health Organisation.
World Health Organization. (2010). Nursing & midwifery strategic directions 2011-2015. Retrieved from www.who.int/hrh/nursing_midwifery/en/
© 2012 OJIN: The Online Journal of Issues in Nursing
Article published May 31, 2012
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