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3/31/2015 RisingtotheChallengeofHealthCareReformwithEntrepreneurialandIntrapreneurialNursingInitiatives

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RisingtotheChallengeofHealthCareReformwithEntrepreneurialandIntrapreneurialNursingInitiatives

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...theuniqueskillsheldbygeneralistandspecialistnursesareoftenunderutilisedacrossthehealth

Abstract

AnneWilson,PhD,MN,BN,FRCNANancyWhitaker,BPsych(Hon)

DeirdreWhitford,PhD

Healthreformworldwideisrequiredduetothelargelyagingpopulation,increaseinchronicdiseases,andrisingcosts.Tomeettheseneeds,nursesarebeingencouragedtopracticetothefullextentoftheirskillsandtakesignificantleadershiprolesinhealthpolicy,planning,andprovision.Thiscaninvolveentrepreneurialorintrapreneurialroles.Althoughnursesformthelargestgroupofhealthprofessionals,theyarefrequentlyrestrictedintheirscopeofpractice.Nursescanhelptoimprovehealthservicesinacosteffectiveway,buttodoso,theymustbeseenasequalpartnersinhealthserviceprovision.Thisarticleprovidesaglobalperspectiveonevolvingnursingrolesforinnovationinhealthcare.Ahistoricaloverviewofentrepreneurshipandintrapreneurshipisoffered.Includedalsoisdiscussionofasocialentrepreneurshipapproachfornursing,settingsfornurseentre/intrapreneurship,andimplicationsforresearchandpractice.

Citation:Wilson,A.,Whitaker,N.,Whitford,D.(May31,2012)"RisingtotheChallengeofHealthCareReformwithEntrepreneurialandIntrapreneurialNursingInitiatives"OJIN:TheOnlineJournalofIssuesinNursingVol.17,No.2,Manuscript5.

DOI:10.3912/OJIN.Vol17No02Man05

Keywords:nursing,nursingrole,entrepreneurial,intrapreneurial,socialentrepreneurship,FutureofNursing,healthreform

Pressurecontinuestomountashealthsystemsworldwideendeavourtomeettheneedsofthepopulationefficiently,economically,andeffectively.Therearewidespreadconcernsaboutinappropriateskillmixesinthehealthworkforce,difficultyrecruitingandretainingstaff,aswellastheunderutilisationofsomehealthprofessionals(ofwhichnursingisone).Needsbased,patientcentredapproachestocarethatemploymixedworkforceteamsarewidelyadvocatedasessentialforhealthcaresystemstoprovideseamless,affordable,andqualitycarethatisaccessibletoall.Thisapproachtohealthcare,specificallytheutilizationofevidencebasedinterventions,hasdemonstratedimprovedhealthoutcomes(McDermott,Tulip,&Schmidt,2004Rittenhouseetal.,2010).Interdisciplinaryhealthcareteamshavethepotentialtoimproveoutcomes,subsequentlyreducecostsandincreasetimelyaccesstocare(Willens,Cripps,Wilson,Wolff,&Rothman,2011).Ahealthinfrastructurethatisadequatelyfundeddeliversrelevantcareandissupportedbyaworkforcesuitedtothepopulationshealthcareneedsis,therefore,essentialtothedeliveryofhighqualitycare.

Nursescomprisethelargestproportion,upto80%(Hughes,2006),ofthehealthworkforceandareconsideredtobethefrontlinestaffacrossthehealthcontinuuminmosthealthservicesandcountries.Inspiteoftheimmenseandsignificantrolethatnursesplayinthehealthcaresystem,theyareseldomconsideredequalpartnersinmultidisciplinaryhealthcareteams.Asaresult,theuniqueskillsheldbygeneralistandspecialistnursesareoftenunderutilisedacrossthehealthcontinuum.However,thelongawaitedandrecentlyreleasedreportfromtheInstituteofMedicine(IOM)(2010)RobertWoodJohnson



continuum.

InnovationinHealthCare

TheneedfornursestoseekuniquerolesthatsupportawidescopeofpracticeandwhichfulfilgapsinhealthcareisrecognisedintheInstituteofMedicinereport.

Useofcreativitytodevelopanewidea,improveserviceordeliverymethods,ordevelopnewproductsornewwaystouseexistingproductsisafundamentalcharacteristicofentrepreneurship.

FoundationInitiativeentitled,TheFutureofNursing:LeadingChange,AdvancingHealth(FON),indicatedthatnurseshaveanimportantcontributiontomakein...buildingahealthcaresystemthatwillmeetthedemandforsafe,quality,patientcentred,accessible,andaffordablecare(InstituteofMedicine,2010,

p.1).However,inordertodelivertheseoutcomes,itisessentialfornursestopracticetothefullextentoftheirknowledgeandtrainingwhiletransformingthewayinwhichhealthcareisprovidedbyenteringintofullpartnershipswithotherhealthcareprofessionals.

Indeed,researchhasrecognisedthatthereisunrealizedscopeforextendedpracticefornursesworkinginmultidisciplinaryteamswithdoctorsandalliedhealthprofessionals(Buchan&DalPoz,2002).Itisduetothisacknowledgementthatinthepasttwodecadesnursesscopeofpracticehasbroadenedconsiderablywiththedevelopmentandimplementationofadvancedandspecialistnursingroles,suchasthatofthenursepractitionerandtheadvancedpracticenurse,implementedthroughnewmodelsofpractice.Theseexpandedroleshavebeenimplementedinmultiplecaresettingsacrossthecontinuumofcarefromcommunityorpublichealthservicesandprimarycare,toacutecare,andsupportiveorlongtermcare.

Inthisarticle,wewilldiscusshowemergingandevolvingentrepreneurialandintrapreneurialrolesinnursingarerisingtomeetthechallengeofhealthcarereformsthroughouttheglobe,acrossthecontinuumofhealthcare.Ahistoricaloverviewofentrepreneurshipandintrapreneurshipisoffered.Weoffersocialentrepreneurshipasasustainablemodelofenterprisingnursedirectedhealthcareanddescribebriefexamplesofsettingsfornurseentre/intrapreneurship,andimplicationsforresearchandpractice.

Innovationsinhealthcaredirectedtowardsimprovedhealthoutcomes,diagnosticandtreatmentoptions,aswellastheefficiencyandcosteffectivenessofthehealthcaresystemarefrequentlyconsideredtheresultofinformationtechnologyratherthanhumanfactors.TheneedfornursestoseekuniquerolesthatsupportawidescopeofpracticeandwhichfulfilgapsinhealthcareisrecognisedintheInstituteofMedicine(2010)report.Innovativeandcreativehealthcareprovidedbyentrepreneurialandintrapreneurialnursesacrossallhealthsettingsisonewayofexpandingthehumaninfluenceofinnovativehealthcare.

EntrepreneurshipinNursing

Nursingentrepreneurshipprovidesnurseswithselfemploymentopportunitieswhichallowthemtopursuetheirpersonalvisionandpassiontoimprovehealthoutcomesusinginnovativeapproaches.Similartootherentrepreneurs,anurseentrepreneurisconsideredtobeaproprietorofabusinessthatoffersnursingservicesofadirectcare,educational,research,administrativeorconsultativenature(InternationalCouncilofNurses,2004,p.4).Assuch,thenurseisselfemployedandisdirectlyaccountabletotheclient(e.g.,individual,private,orpublicorganisation)forwhomtheyprovideservices(Liu&D'Aunno,2011).Suchnursesmayconductanindependentclinicalpracticeownabusiness(e.g.,nursinghomeorpharmaceuticalcompany)orrunaconsultancybusinessin,forexample,educationorresearch.Thus,nurseentrepreneursareinnovatorswhoinitiateincentivesthatleadtochange,themodernisationofhealthsystems,anddemonstrationofleadership(Raine,2003).

Useofcreativitytodevelopanewidea,improveserviceordeliverymethods,ordevelopnewproductsornewwaystouseexistingproductsisafundamentalcharacteristicofentrepreneurship.Combiningthesecharacteristicswithadvancedorspecialistskillsandknowledge,attheveryleast,entrepreneurialnursesareadvancedpracticenurseswhocreateproductsorserviceswhichtheycanmarkettoexternalsources.



...entre/intrapreneurialnurseswillgenerallyoperateatanadvancedlevelduetotheapplicationofahighlydevelopedsetofknowledgeandskills.

...anurseintrapreneurisasalariedemployee,oftenofagovernmentrunhealthservice,whodevelops,promotes,anddeliversaninnovativehealthornursingservicewithinahealthcaresetting,suchashospitalornurseledclinic.

...entreandintrapreneurshipisdefineddifferentlyacrossprofessionsandcountries.

IntrapreneurshipinNursing

Incontrasttoanentrepreneur,anurseintrapreneurisasalariedemployee,oftenofagovernmentrunhealthservice,whodevelops,promotes,anddeliversaninnovativehealthornursingservicewithinahealthcaresetting,suchashospitalornurseledclinic(Hewison&Badger,2006).NurseshavebeendevelopingintrapreneurialventuressincethetimeofFlorenceNightingalehowever,itisonlynowwithincreasingdemandforsafe,highquality,andeffectivehealthcareservicesthatmoreresourcesarededicatedtonursesassumingawidervarietyofroleswithmoreresponsibility.

Nurseintrapreneursdevelopinnovativehealthpracticesfromwithintheorganisationalframeworkinwhichtheywork,andconsequentlysharetherisksandbenefitsassociatedwiththisinnovativepracticewiththeiremployer(Dayhoff&Moore,2005).Thetypeofinnovationsdevelopedbyintrapreneursofteninvolveeffortstotransformworkplaceclimateorculture,improveprocesses,ordevelopnewproductsorservices(Drucker,1985).Intrapreneursareoftenmotivatedbytheneedsoftheirpatientstoidentifygapsinservicethatcanbeaddressedthroughthedeterminedworkofahealthcareteamthatmayormaynotincludethemselves.

TheSimilarities

Althoughdefinedbythecontextofhowtheypractice,ratherthanthepositiontheyhold,entre/intrapreneurialnurseswillgenerallyoperateatanadvancedlevelduetotheapplicationofahighlydevelopedsetofknowledgeandskills.Thereareseveralpersonalitycharacteristicssharedbybothentreandintrapreneurialnurses.Theseincludeselfconfidence,courage,integrity,selfdiscipline,andtheabilitytotakerisks,dealwithfailure,andarticulatetheirgoals(Cooper,2005Wilson&Averis,2002).Aconceptualmodeldepictingthesalientcharacteristicsofthenurseentrepreneur(Wilson&Averis,2002),includinginternalandexternalinfluences,advantages,andchallenges,maybesimilarlyappliedtothenurseintrapreneurwithintheemployedsetting.Itisessentialtobothentreandintrapreneurialventuresthatthenursesareabletoseizeopportunitiestoaddressgapsinserviceprovisionareprovidedtheinfrastructuresupporttodosoandareabletoexplainwhattheyaredoing,whytheyaredoingit,andhowserviceshouldbeprovidedinthefuture

(Cooper,2005).

TheDifferences

Duetoavarietyoffactors,itisdifficulttodeterminehowmanynursesareworkinginentreandintrapreneurialrolesthroughouttheworld.Forinstance,entreandintrapreneurshipisdefineddifferentlyacrossprofessionsandcountries.Thustheconceptofnursesasentrepreneurialmaynotbewidelyunderstoodorrealisedinsomeareas/cultures.

Nurseentrepreneursmayworkasindependentcontractorsanditisoftendifficulttosystematicallyrecordthenumberofnursesoutsideofthepublicandprivatesystemsbyroleandskillmix.Insomeregions,demographicsmaynotexist.Inaddition,somecountriesmaynotrecogniseindependentnurses,whoownandruntheirownprimaryhealthpractices,tobenursesatall(Manion,1991).

FiguresgatheredbytheInternationalCouncilofNursesestimatedthat0.51%ofregisterednursesworldwideworkinentrepreneurialroles.Actualnumberswithinindividualcountriesmaybelowerorhigherasestimatesofnursesormidwiveswhoareselfemployedorownprofessionallyrelatedbusinessesareaslowas



HistoricalOverviewofEntrepreneurshipandIntrapreneurship

Fornursestobefullpartnerswithotherhealthprofessionals,ignoranceandconfusionabouttheirroleandrelationshipwithothercareproviders,fiscalissuesaffectingfeesettingandclientreimbursement,andlegalissuesneedtobeaddressed.

approximately0.1%inNewZealand(Drennanetal.,2007)and0.18%intheUnitedStates(Cheater,2010)andashighas18%intheUnitedKingdom.However,itappearsmorecommonformidwivestobeselfemployedwithestimatesof50%selfemployedinNewZealandand64%intheNetherlands.InAustralia,numbersareunknownasthemostrecentAustralianInstituteofHealthWorkforceNursingandMidwiferyLabourForceSurvey(2009)doesnotmentionselfemployednurses,althoughnumbersaregenerallythoughttobelow.Betterdatacollectionandinformationinfrastructureisrequiredfortargetedhealthworkforceplanningandthisneedisevidentworldwide(InstituteofMedicine,2010).

Historically,therehavebeenchallengesandbarrierstoentreandintrapreneurshipinitiativesbynurses.However,theemphasisonhealthcarereformhassupportedthisevolvingnursingrole,andsomeprogresshasbeenmade.

GlobalChallenges

Theneedforhealthcarereformgloballyremainsapriority.Nevertheless,thelargestgroupofhealthprovidersthenursingandmidwiferyworkforceis,onagloballevel,understaffed,undertrained,andpoorlydeployed(WorldHealthOrganization,2010).Nursingsscopeencompasses:

...autonomousandcollaborativecareofindividualsofallages,families,groupsandcommunities,sickorwellandinallsettings.Itincludesthepromotionofhealth,thepreventionofillness,andthecareofill,disabledanddyingpeople.(WorldHealthOrganisation,2010,p.55).

Consequently,nursesarewellabletobefrontlineserviceprovidersactingbothasindividualsandasmembersandcoordinatorsofinterprofessionalteams.Inspiteofthebreadthofservicesprovidedbynurses,nursinginsightintohealthneedsacrossthecontinuum,andrecognitionthatnursesandmiwivesarepivotaltohealthservices,nursesandmidwivesarenotoftenidentifiedaskeystakeholdersinthedevelopmentofhealthpolicy.Inaddition,theyarefrequentlynotequalpartnersonhealthteams.

BarrierstoSelfEmployment

Fornursestobefullpartnerswithotherhealthprofessionals,ignoranceandconfusionabouttheirroleandrelationshipwithothercareproviders,fiscalissuesaffectingfeesettingandclientreimbursement,andlegalissuesneedtobeaddressed(Caffrey,2005Wilson,Averis,&Walsh,2004).Studiesundertakenin2002(Wilson&Averis,2002),and2004(Wilson,etal.,2004)indicatedthatresearchintoentrepreneurialnursingremainslimitedandinsufficienttoinformchangestohealthpolicyandnurseeducation.

Barrierstoselfemploymentfornursesremain.Lackofrecognitionsuchasthataffordedtootherselfemployedhealthserviceproviderscontinuesalongwithprofessionalisolation,lackofasafetynet,andresistanceorhostilityfromcolleagues.Inadditiontothepreviouslymentionedabsenceofreliablefiguresonthenumberofnursesworkinginentre/intrapreneurialroles,thereisalsoalackofresearchtosupportchangestothehealthsystemrequiredtotakefulladvantageofnursesworkingintheseroles.Specifically,therehasbeenlittleresearchtoprovidepracticalguidesforhealthsystemsworldwidetoimplementinnovativenursingrolessuccessfullyasnursesinentreorintrapreneurialrolesoftenfacebarrierstoeffectivepractice.Thereisalsoalackofresearchfindingstoinformchangestonursingeducationsothatnursesmayenvisionandpursuesuchroles.

HealthcareReformandtheFutureofNursing

In2008,amajorinitiativebeganwiththeintentiontoassessandtransformthenursingprofessionastheUnitedStateshealthcaresystemunderwentmajorchanges.AtwoyearprojectwaslaunchedbytheRobert



Historically,innovationandentrepreneurshipinnurseeducationhavebeenavoidedbecausedominantvaluesareacceptance,standardisation,andprescription.

ASocialEntrepreneurshipApproachforNursing

Socialentrepreneurshipisanapproachthatinvolvesthedesignandimplementationofinnovativeideasandpracticalmodelsforachievingasocialgood.

WoodJohnsonFoundation(RWJF)withtheInstituteofMedicinewiththeintenttoreleaseareportthatwouldmakerecommendationsforanactionorientedplanforthefutureofnursing(InstituteofMedicine,2010).

TheFutureofNursingreportidentifiedthatnurses,workingattheforefrontofpatientcare,canplayavitalroleinhelpingtorealizeobjectivestomakehealthcareaccessible,acceptable,andaffordable.Beforethiscanoccur,barrierstopreventnursesfromrespondingeffectivelytorapidlychanginghealthcaresettingsandanevolvinghealthcaresystemneedtobeaddressed.Thennurseswillbeevenbetterpositionedtoleadchangeandadvancehealth(InstituteofMedicine,2010).Barriersincludenursesinabilitytopracticetotheirfullextent,lackofaccesstoaneducationsystemthatallowsforseamlessprogressiontohigherlevels,andlackofopportunityforfullpartnershipwithotherhealthcareprofessionals.Otherneedsareimprovedresearch,betterdatacollection,andinformationinfrastructureonhealthcareworkforcerequirements.

Historically,innovationandentrepreneurshipinnurseeducationhavebeenavoidedbecausedominantvaluesareacceptance,standardisation,andprescription(Robinson,2008).Directedrecruitmentandeducationstrategiesareneededtopreparenursesforentre/intrapreneurialrolestoprovideleadership,coordinatecare,andestablishmultidisciplinarypathways.ThisistruenotjustintheUnitedStates,wheretheFONreportwasgenerated,butworldwide.Therearerisksandbarriersinbeinginnovativeandaleader.But,fornursestogainanequalplacebothintheworkplace(andaroundthepolicytable),theyneedtobeencouragedtobeconfidentintheirskills(Liu&D'Aunno,2011).

ProgresstoDate

Acollaborativeenvironmenttocapitalizeonentrepreneurialskillsofadvancedpracticeandspecialistnursesisrequiredforhealthplannersandnursestorealizetheirvision(Austin,Luker,&Roland,2006).Someprogresshasbeenmadetodate,butnotwithoutcontinuedchallenges.

IntheUnitedStates,nursepractitioners(NPs)havedirectednursemanagedhealthcentres(NMHC)inlocationsthataremedicallyunderservedtoprovideasafetynetforMedicaidrecipientsanduninsuredcitizens(HansenTurton,Bailey,Torres,&Ritter,2010).Inthesecentres,NPsprovidehighqualityandcosteffectivecarewhichhasbeenfoundtoencouragehigherratesofgenericmedicationfillsandlowerratesofhospitalisation(HansenTurton,Line,OConnell,Rothman,&Lauby,2004).Theseserviceshavehighpatientsatisfactionscores,asiscommonformanyNPmanagedprimaryhealthservices.

However,itcanbedifficultforthistypeofnurseledservicetoattainfinancialsustainabilityastheyrelyonMedicaidandMedicarereimbursement,privategrants,andgovernmentfunding.MostoftheseNMHCsareoperatedbynursingschoolsandsomereceivefundingfromtheseparentorganisations.Thiscanlimittheleveloffundingthecentresreceivefromthefederalgovernment.Inadditiontothisdifficulty,48%ofmanagedcareinsurersdonotreimburseNPsprovidingprimarycare(anillegalpractice)however,thislawcontinuestogounenforced(HansenTurtonetal.,2010).ThefinalhurdlefacedbytheseNPledprimaryhealthcareservicesisprimarycarephysicians'associationsworkingtodefinesoleprimarycareprovidersasphysiciansonly.Resistancefrommedicalassociationstonurseledservicesisnotuncommonandneedstobeaddressedforeffectivehealthreformthatfeaturesnursesinfullscope,innovativeroles,suchastheentrepreneurialNMHCsabove,tosucceed.

Socialentrepreneurshipisoneapproachthatiswellsuitedtonurseentrepreneursandmayincreasesuchopportunitieswithintheprofession.Whilemostentrepreneurshipenterprisesarecommonlyviewedasbusinessventuresintendedtoachievefinancialgain,innursing,entrepreneurshipcouldbeviewedasseekingtoachievegoodhealthoutcomesforthemostnumberofpeople.Assuch,theseinitiativesrepresentexamplesofnursesdoinggoodforthelargersociety.Socialentrepreneurshipisanapproachthatinvolvesthedesignandimplementationofinnovativeideasandpracticalmodelsforachievingasocialgood(Cheater,2010Gilliss,2011).



Intra/entrepreneurialnursingmayoccuratanypointinpartnershiporseparately.

SettingsforNurseEntre/Intrapreneurship

Incontrasttothetraditionalbusinessapproachofentrepreneurs,asocialentrepreneurfocusesoncreatingsocialreturns.Thus,themainaimofsocialentrepreneurshipistofurthersocialandenvironmentalgoals.Althoughsocialentrepreneursaremostcommonlyassociatedwiththevoluntaryandnotforprofitsectors,itneednotexcludemakingaprofit(Thompson,2002).Takingthesocialentrepreneurshipapproachinhealthreformplacesnursesonacommonplatformwithpeoplewhohavenoticedaneedanddevelopedawayofremedyingthatissue.

Ifnursingistobuildsustainable,nursedirected,socialhealthmodelsofcarethataddressgapsinhealthcaretoday,wewillberequiredtodemonstratehighimpactandeffect,whicharethedatasoughtbyhealthfundersatstateandfederallevels.Approachingentrepreneurshipinnursingfromasocialheathperspectivemayenabletheinnovationandcreativityneededforsuchanimpacttobemoreacceptablewithintheprofession.Furthermore,visibilityandarticulationoftheworkofnurseentrepreneurswillhopefullyhelpsocietybegintounderstandhowlongstandingproblemsandineffectiveand/orinefficientmodelsmightbeaddressedinnewways.Forexample,theUnitedKingdomHighQualityforAllreviewindicatedthatitwastheresponsibilityofhealthprofessionalstoleadserviceimprovementinitiativesatthelocallevel(Coddington,Sands,Edwards,Kirkpatrick,&Chen,2011).Asaresultofthisreport,primarycaretrustboardsarenowrequiredtoconsiderproposalsfromNationalHealthService(NHS)staffonhowtoimproveserviceslocallythroughthecreationofsocialenterprises.

Threeparadigmsencompassthehealthcareservicesprovidedacrossthecontinuumofcare.Thesearegenerallyreferredtoprimary,secondary,andtertiarycare.Anarrangementofpreventivepublichealthservices,primarycareoutpatientclinics,localgeneralhospitals,andregionalhospitalswithintensiveandspecialtycareunitsisembeddedinthearrayofservices.Withineachofthesehealthcaresectors,therearearangeofservicesavailablebothinternallyand,toalesserextent,externallytoaddresscommunityhealthandwellnessneeds.

Althoughmanyindividualsaccesstheseservicesinonesetting,therearefewpopulationswhichbenefitfromcareacrossthethreesettingsinashortperiodoftime.Olderpersonsoftensufferfromcomorbidandchronicillnessesandthereforerequireaccesstoservicesacrossthiscontinuumofcare.Theseservicesmayoftenbeinitiallydeliveredthroughhomehealthagencies,followedbyassistedliving,andthencareinaskillednursingfacilityasthepatientshealthdeclines.Theoretically,consumersentercareatthelowestlevelcapableofaddressingtheirproblem(s)andthenadvancetohigherlevelsonlyastheircarebecomesmorecomplex.Inpractice,theservicesmayoverlap,especiallyprimaryandsecondarycaresettings,andthispatientsmayaccesscareinamorecircularfashiondependingonneedforservices.

Duetofactorssuchasfinancial,geographical,andculturalbarrierstoaccessingcareandlackofinformationtoassistconsumerstomakehealthcarechoices,thecontinuumofcareisatheoreticalmodelratherthananactualsystemofcaredelivery.ThemodeldepictedinFigure1canbeusedtodescribehowapatientmaytheoreticallymovethroughthehealthcaresystemorenterandexitthesystematanygivenpoint.Itishelpfultoillustratethemanyopportunitiesandvarietyofsettingsforentre/intrapreneurialroles.Intra/entrepreneurialnursingmayoccuratanypointinpartnershiporseparately.Below,weoffersomeexamplesofhownurseentrepreneursandintrapreneursareprovidingcareacrossthecontinuumateachofthethreelevelsofcare.

Figure.TheContinuumofHealthcare



Theintroductionofentreandintrapreneurialrolesintotheprimarycaresettingisexpectedtoresultinevenmoretimelyaccess

(viewfullsizefigure[pdf])

PrimaryCare

Nursesplayavitalrolethroughoutthecontinuumofcareandworkinbothentrepreneurialandintrapreneurialrolestoservetheprimarycareneedsofthecommunity.Inthecontextofglobalpopulationaging,withincreasingnumbersofolderadultsatgreaterriskofchronic,noncommunicablediseases,rapidlyincreasingdemandforprimarycareservicesisexpectedaroundtheworld.Thisistrueinbothdevelopedanddevelopingcountries.TheWorldHealthOrganization(2000)citestheprovisionofessentialprimarycareasanintegralcomponentofaninclusiveprimaryhealthcare.Newwaystoaddressoldproblemsareneeded.

Inprimarycare,intrapreneurialnursesworkinthelocalcommunityasafirstpointofconsultation,providingroutinehealthscreening,preventivecare,andhealtheducationtoavoidtheoccurrenceofdisease.Nursesinthissettingoftenalsoprovidecareforstablepatientssufferingfromcommonchronicillnessessuchashypertension,diabetes,asthma,chronicobstructivepulmonarydisease(COPD),depressionandanxiety,backpain,arthritis,andthyroiddysfunction(Campbell,2009).Primarycarealsoincludesmanybasicmaternalandchildhealthcareservicessuchasfamilyplanningservicesandimmunisation.Inprimarycare,nurseswithadvancedorspecialistqualificationsoftenprovidecarethroughnurseledcommunityhealthclinics.

NurseintrapreneurshavebeeninvolvedinproducingmoreeffectiveprimarycarethroughprogramssuchasthatdevelopedbyMaryNaylorandKarenBuhlerWilkersen(UniversityofPennsylvaniaSchoolofNursing)whodevelopedaninnovativeprogramforimprovingeldercareintheircommunity.Theseintrapreneursestablishedacommunitybasedpracticeemployingadvancedpracticenursestoofferfunctionalsupportandmultidisciplinaryservicesforolderpersonswithcomorbidities.Theprogramallowselderlypeopletoremainintheirhomesratherthanbeforcedtoenterresidentialcarefacilities.NaylorandBuhlerWilkerson(1999)said,

...ifwearesuccessfulinrealizingourdreamsthroughLIFE,wewillhavearticulatedaconceptforcommunitybasedcareforthenewmillenniumthatembracestheleadershipofnursesinofferinginnovativeandpracticalsolutionstothecomplexneedsofhighrisk,vulnerablepersonsandtheirfamilies(Naylor&BuhlerWilkerson,1999,p.127).

Indeed,recentliteratureindicatesthatthisprogramhas,andcontinuestobe,ahighlyeffective,costefficient,sustainable,andessentialenterprise(TheUniversityofPennsylvania,2008).Thesuccessofthisprogramisindicativeofthepowerthatintraandsociallyentrepreneurialnurseshaveinbuildingandsustainingprimarycareservices.

Theeffectivenessofintra/entrepreneurialnursesworkinginprimarycarehasbeendemonstratedinstudieswhichfoundthat93to100%ofclientswerecompletelyorverysatisfiedwiththequalityofcareprovided(Coddington,etal.,2011MoralesAsencioetal.,2008).Forexample,anentrepreneurialnursemanagedpaediatricclinicenabledclientstodeveloptherapeuticrelationshipswiththenursepractitioners,removedbarrierstocaresuchastransportationbyprovidingregionalservices,andimprovedhealthcareaccess(Coddington,etal.,2011).

Theintroductionofentreandintrapreneurialrolesintotheprimarycaresettingisexpectedtoresultinevenmoretimelyaccesstoservices.Thiswilltherebyincreasetheefficencyandeconomyofthisfirststepinthehealthcaresystemandsubsequentlyreducepressureonthesystemathigherlevesofcare.Theseoutcomeswillresultfromanexpandedscopeofnursingpracticeinthissetting,sothatentrepreneursandintrapreneurscantakeondutiespreviouslyinthedomainofdoctorsonly.Itisalsobelievedthatnursesworkinginthiswaymayremovethedemarcationbetweenprofessionalgroups,thuspromotingequalpartnershipsamonghealthprovidersfromvariousdisciplines(Traynoretal.,2008).



toservices.

...nursesworkinginthiswaymayremovethedemarcationbetweenprofessionalgroups,thuspromotingequalpartnershipsamonghealthprovidersfromvariousdisciplines.

Nurseintrapreneursworkwithinhospitalstoimprovetheservicesprovidedandinformfuturedirectionforimprovementstohospitalpolicyandtraining.

Onewaythathealthcarereformeffortsinmultiplecountriesaremovingtowardthisgoalisthroughtheintroductionofnursepractitionerstoexpandtheprimarycareworkforce.Theseinitiativeshavebeenrecognisedasafeasibleandeffectivesolutiontoeasetheshortageofprimarycarephysiciansinmanycountries.However,theproductivityandcostefficiencyofNPsisdependentonseveralfactors,includinglengthofconsultationsandpatientload(Browne&Tarlier,2008).Anadditionalconsiderationisthatpatientsreportmoresatisfactionwithusingprimarycarepracticesettingsthansecondarycareservices(e.g.,accidentandemergency)totreatnonlifethreateningconditions(Hutchison,2003).

SecondaryCare

Secondarycaremaybeprovidedinthecommunityorinahospitalandsimilarsettings.Thefocusofthiscareistypicallytreatmentforshorttermacuteillnesses,injury,orotherhealthconditionsinordertodiagnoseandtreatdiseaseintheearlystagesbeforeitcausesmorbidity.Growthinthesecondarycaresectorisnotedduetotheincreasedrateofpresentationtoemergencydepartmentsforpatientswhobypassprimarycare(oftenvulnerablepopulationssuchasthosewithoutinsurancecoverage)andoverloadproblemsintertiarycare(Harris,Patel,&Bowen,2011Hulletal.,2000).

Nurseintrapreneursworkwithinhospitalstoimprovetheservicesprovidedandinformfuturedirectionforimprovementstohospitalpolicyandtraining.Intrapreneursworkinginsecondarycarehaveconductedsuccessfulprogramssuchasnursetriageinemergencydepartmentforpsychiatricpatients(Happell,Summers,&Pinikahana,2002).Casefindingisperformedusingasimplescreeningassessmentcompletedbytheprimaryortriagenursefollowedbyanindepthinterviewbyageriatricclinicalnursespecialist.Patientswithunmetmedical,social,orhealthneedsarereferredtotheirprimaryphysicians,tooutpatientgeriatricevaluationandmanagementcentres,ortocommunityagencies(Mion,2001).

Theeffectivenessandfeasibilityofintrapreneurialnursepractitionersinconductingclinicssuchasthoseforminorinjuriesinemergencydepartmentsiswelldocumented(Wilson&Shifaza,2008Wilson,Zwart,Everett,&Kernick,2009).AdevelopingareaofsecondarycareinAustraliaistheGeneralPractice(GP)PlusandSuperclinicswhicharelocatedinlargecommunitiesandprovidebothprimaryandsecondaryserviceswithaccesstoalliedhealthteams,nursepractitioners,generalpractitionersmedicalspecialists,imaging,anddentalcare.

AnotherinnovationistheintroductionofentrepreneurialSmartClinicsorprivatelyfundedstandalonenursepractitionerledclinicsinAustralia(SmartClinics,2010).Theseclinicsofferanincreasedconnectiontoeverydaycarebylocatingineasytoaccesslocationsandoperatingoutsidenormalbusinesshours.EverySmartClinicNPholdsaMastersofNursingdegree,nursepractitionerendorsement,andisregisteredwiththeAustralianHealthPractitionerRegulationAgency.ThecarepatientsreceiveatSmartClinicsispurportedlyunderpinnedbycurrentevidencebasedclinicalguidelines,allofwhicharedefinedbytheirChiefMedicalOfficer.TheSmartClinicsadvertisethattheyprovidepersonalised,patientcentredcare(SmartClinics,2010).

AprivatenurseledcommunityhealthclinicestablishedinMelbourne,Australiaacceptsreferralsfromhospitalsandalliedhealthprofessionalsandprovideschronicdiseasemanagement,preventivehealthcare,riskidentification,woundcare,medicationadministration,carersupport,andadvice(Campbell,2009).PositivefeedbackisreceivedfromGPsintheareahowever,thenursesarelimitedbylackofMedicareitemnumbersandthereforeareunabletobulkbillorchargeratessimilartothosechargedbyotherhealthprofessionals.

TertiaryCare

Tertiarycareisspecializedconsultativehealthcare,usuallyforinpatientsinafacilitysuchasanacutehospitalthathaspersonnelandfacilitiesforadvancedmedicalinvestigationandtreatment.Methodsofcarefocuson



Oneissueforintrapreneurialnursesworkingwithinanorganizationwheretertiarycareisprovidedisdealingwithahierarchyinwhichdoctorsareoverrepresentedinpolicyformationandseniormanagementpositions.

ImplicationsforResearchandPractice

Somenursesarealreadyworkinginentreandintrapreneurial

reducingthenegativeimpactofdiseasebyrestoringfunctionandreducingrelatedcomplications.Patientsarefrequentlyreferredfromaprimaryorsecondarylevelhealthprofessionalandmaybedischargedtothemforfollowupcare.Nursesintertiarycaregenerallydonothavefirstcontactwithpatients,andservicesmayincludecardiologyclinics,urology,oncology,andburntreatment,andeldercarefacilities(Caffrey,2005Schadewaldt&Schultz,2011).

Asystematicreviewsummarisingtheevidenceofsevenrandomisedcontrolledtrialsreportedthat,althoughtherewerenoharmfuleffectsidentifiedinpatientswithcoronaryheartdiseaseexposedtoanurseledclinic,inconsistenciesintheinterventionsusedmadecomparisondifficult(Schadewaldt&Schultz,2011).Themajorinterventionconsistedofhealtheducation,counsellingbehaviourchange,andpromotionofahealthylifestyle.Althoughafewriskfactorsweresignificantlyreducedintheshorttermbyattendingnurseledclinics,longtermchangeswerelessapparent,possiblybecausethesuccessofmodifyingbehavioursuchassmokingcessationanddietadherencewaslimited.

However,intrapreneurialnurseledservicesmaypositivelyinfluenceperceivedqualityoflifeandgeneralhealthstatusforthispopulation.Inordertodeliverthehealthcareneededbyconsumerswithbothcomplexandsimpleneeds,itisessentialtohavehealthcareprofessionalsavailabletoassistwithtransitionbetweenandacrossthelevelsofcare.Nursesareworkingtomeetthisneedthroughthedevelopmentofinnovative,entrepreneurialandintrapreneurialrolesatallofthesecarelevels.Toprovideservicesthatmeetindividualsneeds,andareequitableandeconomical,bothoftheseapproachesarerequired(Hewison&Badger,2006).

Oneissueforintrapreneurialnursesworkingwithinanorganizationwheretertiarycareisprovidedisdealingwithahierarchyinwhichdoctorsareoverrepresentedinpolicyformationandseniormanagementpositions.Thisoftendiscouragesnurseschallengingphysicianpracticeandmaydenythemtheabilitytoopenlyquestiondecisionswhentheyhaveaconcern.(Churchman&Doherty,2010).Thisculturepreventsinnovationbecauseinnovatorssuggestionsforchangetendtobedismissed.

Discussion

Theseexamplesofnurseentreandintrapreneursworkinginprimary,secondary,andtertiarycaredemonstratepotentialbenefitstopatientsandthevarietyofsettingsfornurseentre/intrapreneurs.Patientsvaluetheproblemsolvingapproachandadvocacythatnursesprovide,whilenursesfeelsupportfortheircareandenjoyprovidingcontinuityofcare(Caffrey,2005).Ourfindingsindicatedthattherewasnogreaterriskofpooreroutcomesinthenurseledclinics,althoughtheeffectivenessofclinicsmightbedependentontheintensityofthenursingsupport.Fromtheliteraturerevieweditisevidentthatthecombinationofcounselingandregularassessmentofriskfactorsandhealthstatusdeliveredatnurseledclinicsissupportedbytheavailableresearch.Giventhatoutcomeswere,ingeneral,equivalentbetweennurseled(i.e.,nurseentreorintrapreneurs)andothertypeclinics,itwouldbebeneficialforfurtherresearchtoinvestigatethecosteffectivenessofthedifferentmodelsofcare.

Healthreformworldwideisneededduetothesubstantialagingpopulationandincreaseinchronicdiseases(e.g.,diabetes,asthma).Tomeetfutureneeds,wemustenablenursestopracticetothefullextentoftheirskills.Nursescanhelptoimprovehealthservicesinacosteffectiveway,buttodoso,theymustbeperceivedasequalpartnersinhealthserviceprovision.

Somenursesarealreadyworkinginentreandintrapreneurialroleswhichdemonstratethepositiveoutcomesthatcanbeachievedwhennursesmeettheirfullpotential.Thesenursesareworkingacrossthecontinuumofcare.Itseemsobviousthatentrepreneurialnursingrolesareforgingthewayforthistypeofpartnershipbyexamplesofnursesconductingclinicsinprimaryandsecondarycareandasspecialiststomanageexacerbationsofchronicillnessin


http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol172012/No2May2012/RisingtotheChall 10/13

roleswhichdemonstratethepositiveoutcomesthatcanbeachievedwhennursesmeettheirfullpotential.Thesenursesareworkingacrossthecontinuumofcare.

Authors

References

tertiarycaresettings.

Nurseintrapreneursare,toalesserextent,alsobeingrecognisedaspartners.Researchonnurseledinitiativeswithinhospitalsinparticularislimited.Researchthatconfirmstheimportanceoftheserolestoprovideimprovedhealthoutcomesandtoinformhowthismaybeachievedpracticallyisrequired.

Werecommendseveralactionsorstrategiestopromoteentreandintrapreneurshipinnursing.Thesemayinclude:

Nurseeducationthatincludesplacementwithanurseentrepreneurand/orabusinesscoursetoensurethatgraduatingnurseslearnskillstolead,challenge,andbeinnovative.Interdisciplinarylearningsothatalliedhealthandmedicalprofessionalsareintroducedtotheconceptofnursesasequalpartnersinhealthcare.Greateropportunitiesofsharedinterdisciplinarycollaborationinresearch,education,andpracticetofostercohesionandrolefamiliarityamongsthealthprofessionals.

Healthreformisincreasinglytargetedtowardsstrengtheningandexpandingprimaryhealthsystemsascareisshiftedfromhospitalstocommunities.Therenewedemphasisonpreventionandhealthpromotionisintendedtocurbthetideofchronicdiseaseandsustaineffectivechronicdiseasemanagement,aswellasaddresshealthinequitiesandincreaseaffordableaccesstoservices.Giventhefullpotentialscopeofnurses'practice,thesuccessofhealthsystemreforms(suchasthoseintheUnitedStatesandAustralia)dependonanursingworkforcethatisappropriatelyeducatedandsupportedforinnovativepracticerolesinmultiplesettings.

AnneWilson,PhD,MN,BN,FRCNAEmail:[email protected]

AnneWilsonisanexperiencedclinicianandacademic.Annehasabackgroundinprimaryhealthcarewithextensiveexperienceinprovidingprimaryhealthcareservicesincommunityhealth,youth,childandmaternalhealth,earlyintervention,healthscreeningandsurveillance.Threesignificanthighlightsofhercareerwereestablishingaprivatepracticeasanurseentrepreneur,workingintheremoteKimberleyRangesofWesternAustraliaandasacommunitymidwifeinScotland.

NancyWhitaker,BA(Hons),MPsychEmail:[email protected]

NancyWhitakerreceivedherBachelorofPsychology(Honours)fromFlindersUniversity,Adelaide(Australia).SheisnowworkingintheUniversityofAdelaideSchoolofNursingasaresearchassistantwhilestudyingherMasterofPsychology(Clinical),alsoattheUniversityofAdelaide

DeirdreWhitford,PhDEmail:[email protected]

DeirdreWhitfordisanAssociateProfessorClinicalPractice(Adjunct)fortheSchoolofPopulationHealthattheUniversityofAdelaide.Herresearchandeducationinterestsarepopulationandpublichealth,theepidemiologyofstroke,thehealthservicesworkforce,andfactorsaffectingstudentrecruitmenttoruralandindigenoushealthsettingplacements.

Austin,L.,Luker,K.,&Roland,M.(2006).Clinicalnursespecialistsasentrepreneurs:Constrainedorliberated.JournalofClinicalNursing,15(12),15401549.

Browne,A.J.,&Tarlier,D.S.(2008).Examiningthepotentialofnursepractitionersfromacriticalsocialjustice



perspective.NursingInquiry,15(2),8393.

Buchan,J.,&DalPoz,M.R.(2002).Skillmixinthehealthcareworkforce:Reviewingtheevidence.BulletinoftheWorldHealthOrganization,80(7),575580.

Caffrey,R.A.(2005).Independentcommunitycaregerontologicalnursing:Becominganentrepreneur.JournalofGerontologicalNursing,31(8),1217.

Campbell,J.(2009).Privatenurseclinic.TheAustraliannursingjournal17(6),17.

Cheater,F.M.(2010).Improvingprimaryandcommunityhealthservicesthroughnurseledsocialenterprise.QualityinPrimaryCare,18(1),57.

Churchman,J.J.,&Doherty,C.(2010).Nurses'viewsonchallengingdoctors'practiceinanacutehospital.NursingStandard,24(40),4248.

Coddington,J.,Sands,L.,Edwards,N.,Kirkpatrick,J.,&Chen,S.(2011).Qualityofhealthcareprovidedatapediatricnursemanagedclinic.JournaloftheAmericanAcademyofNursePractitioners,23(12),674680.doi:10.1111/j.17457599.2011.00657.x

Cooper,M.(2005).Becominganentrepreneur.CanadianNurse,101(4),1415.

Dayhoff,N.E.,&Moore,P.S.(2005).CNSentrepreneurs:Innovatorsinpatientcare.NursePractitioner,68.

Drennan,V.,Davis,K.,Goodman,C.,Humphrey,C.,Locke,R.,Mark,A.,...Traynor,M.(2007).EntrepreneurialnursesandmidwivesintheUnitedKingdom:anintegrativereview.JournalofAdvancedNursing,60(5),459469.

Drucker,P.F.(1985).Innovationandentrepreneurship.Oxford:ButterworthHeinemann.

Gilliss,C.L.(2011).Thenurseassocialentrepreneur:Revisitingourrootsandraisingourvoices.NursingOutlook,59(5),256257.doi:10.1016/j.outlook.2011.07.003

HansenTurton,T.,Bailey,D.N.,Torres,N.,&Ritter,A.(2010).Nursemanagedhealthcenters:Keytoahealthyfuture.AmericanJournalofNursing,110(9),2326.

HansenTurton,T.,Line,L.,OConnell,M.,Rothman,N.,&Lauby,J.(2004).Thenursingcentermodelofhealthcarefortheunderserved.Philadelphia.U.S.CentersforMedicareandMedicaidServices.

Happell,B.,Summers,M.,&Pinikahana,J.(2002).Thetriageofpsychiatricpatientsinthehospitalemergencydepartment:acomparisonbetweenemergencydepartmentnursesandpsychiatricnurseconsultants.AccidentandEmergencyNursing,10(2),6571.doi:10.1054/aaen.2001.0336

Harris,M.J.,Patel,B.,&Bowen,S.(2011).Primarycareaccessanditsrelationshipwithemergencydepartmentutilisation:Anobservational,crosssectional,ecologicalstudy.BritishJournalofGeneralPractice,61(593),e787e793.doi:10.3399/bjgp11X613124

Hewison,A.,&Badger,F.(2006).Takingtheinitiative:NurseintrapreneursintheNHS.NursingManagementUK,13(3),1419.

Hughes,F.(2006).Nursesattheforefrontofinnovation.InternationalNursingReview,53(2),94101.

Hull,S.,Harvey,C.,Sturdy,P.,Carter,Y.,Naish,J.,Pereira,F.,...Parsons,L.(2000).Dopracticebasedpreventivechildhealthservicesaffecttheuseofhospitals?AcrosssectionalstudyofhospitalusebychildrenineastLondon.BritishJournalofGeneralPractice,50(450),3136.

Hutchison,B.,Ostbye,T.,Barnsley,J.,Stweart,M.,Mathews,M.,Campbell,M.K.,...Tyrrell,C.(2003).Patientsatisfactionandqualityofcareinwalkinclinics,familypracticesandemergencydepartments:TheOntarioWalkInClinicstudy.CanadianMedicalAssociationJournal,168(8),977.

InstituteofMedicineoftheNationalAcademies.(2010).Thefutureofnursingleadingchange,advancinghealth.Retrievedfromwww.iom.edu/Reports/2010/TheFutureofNursingLeadingChangeAdvancingHealth.aspx

InternationalCouncilofNurses.(2004).Guidelinesonthenurseentre/intrapreneurprovidingnursingservice.Geneva,Switzerland.

Liu,N.,&D'Aunno,T.(2011).Theproductivityandcostefficiencyofmodelsforinvolvingnursepractitionersinprimarycare:Aperspectivefromqueueinganalysis.HealthServicesResearch,7(2),594613.doi:10.1111/j.14756773.2011.01343.x

Manion,J.(1991).Nurseintrapreneurs:Theheroesofhealthcare'sfuture.NursingOutlook,39(1),1820.

McDermott,R.A.,Tulip,F.,&Schmidt,B.(2004).DiabetescareinremotenorthernAustralianindigenous



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communities.MedicaljournalofAustralia,180(10),512516.

Mion,L.C.,Palmer,R.M.,Anetzberger,G.J.,&Meldon,S.W.(2001).Establishingacasefindingandreferralsystemforatriskolderindividualsintheemergencydepartmentsetting:TheSIGNETmodel.JournaloftheAmericanGeriatricsSociety,49(10),13791386.doi:10.1046/j.15325415.2001.49270.x

MoralesAsencio,J.M.,GonzaloJimenez,E.,MartinSantos,F.J.,MorillaHerrera,J.C.,CeldraanManas,M.,Carrasco,A.M.,Garciaarrabal,J.J.,&ToralLopez,I.(2008).EffectivenessofanurseledcasemanagementhomecaremodelinPrimaryHealthCare.Aquasiexperimental,controlled,multicentrestudy.BMCHealthServicesResearch,8(1),193.

Naylor,M.D.,&BuhlerWilkerson,K.(1999).Creatingcommunitybasedcareforthenewmillennium.NursingOutlook,47(3),120127.doi:10.1016/s00296554(99)900064

Raine,P.(2003).Promotingbreastfeedinginadeprivedarea:theinfluenceofapeersupportinitiative.Health&SocialCareintheCommunity,11(6),463469.doi:10.1046/j.13652524.2003.00449.x

Rittenhouse,D.R.,Shortell,S.M.,Gillies,R.R.,Casalino,L.P.,Robinson,J.C.,McCurdy,R.K.,&Siddique,J.(2010).Improvingchronicillnesscare:Findingsfromanationalstudyofcaremanagementprocessesinlargephysicianpractices.MedicalCareResearchandReview.doi:10.1177/1077558709353324

Robinson,F.(2008).Nurseentrepreneurs.PracticeNurse,36(5),1112.

Schadewaldt,V.,&Schultz,T.(2011).Nurseledclinicsasaneffectiveserviceforcardiacpatients:resultsfromasystematicreview.InternationalJournalofEvidenceBasedHealthcare,9(3),199214.doi:10.1111/j.17441609.2011.00217.x

SmartClinics(2011).Retreivedfromwww.smartclinics.com.au/

TheUniversityofPennsylvania.(2008).LIFEReflections.Retrievedfromwww.nursing.upenn.edu/clinical_practices/Pages/LIFEreflections.aspx

Thompson,J.L.(2002).Theworldofthesocialentrepreneur.TheInternationalJournalofPublicSectorManagement,15(4/5),413.

Traynor,M.,Drennan,V.,Goodman,C.,Mark,A.,Davis,K.,Peacock,R.,&Banning,M.(2008).'Nurseentrepreneurs'acaseofgovernmentrhetoric?JournalofHealthServicesResearch&Policy,13(1),1318.

Willens,D.,Cripps,R.,Wilson,A.,Wolff,K.,&Rothman,R.(2011).Interdisciplinaryteamcarefordiabeticpatientsbyprimarycarephysicians,advancedpracticenurses,andclinicalpharmacists.ClinicalDiabetes,29(2),6068.

Wilson,A.,&Averis,A.(2002).Facetsofprivatepracticenursing:Aconceptualmodel.Collegian,9(2),1621.

Wilson,A.,Averis,A.,&Walsh,K.(2004).ThescopeofprivatepracticenursinginanAustraliansample.PublicHealthNursing,21(5),488494.doi:10.1111/j.07371209.2004.021511.x

Wilson,A.,&Shifaza,F.(2008).Anevaluationoftheeffectivenessandacceptabilityofnursepractitionersinanadultemergencydepartment.InternationalJournalofNursingPractice,14(2),149156.doi:10.1111/j.1440172X.2008.00678.x

Wilson,A.,Zwart,E.,Everett,I.,&Kernick,J.(2009).Theclinicaleffectivenessofnursepractitioners'managementofminorinjuriesinanadultemergencydepartment:Asystematicreview.InternationalJournalofEvidenceBasedHealthcare,7(1),314.doi:10.1111/j.17441609.2009.00121.x

WorldHealthOrganisation.(2000).TheWorldHealthReport,2000Healthsystems:improvingperformance.Geneva:WorldHealthOrganisation.

WorldHealthOrganization.(2010).Nursing&midwiferystrategicdirections20112015.Retrievedfromwww.who.int/hrh/nursing_midwifery/en/

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