ownentrepreneur sept1996 e

Nursing around the world is evolv-ing to meet the changing healthcare needs of the public and the

career goals of nurses. Nurse entrepre-neurship is a global trend and a smallbut increasing number of Canadian reg-istered nurses1 have taken the initiativeto establish their own businesses pro-viding nursing services.

CNA has steadfastly promoted pub-licly funded health care services andthrough their professional associa-tions, nurses are lobbying forincreased public access to essentialnursing services.

Unfortunately, many nursing services inthe home and community (e.g., homecare, nursing homes) are privately fund-ed and publicly funded nursing servicesin hospitals, homes and communitiesare being cut back. CNA would like tosee public funding for “essential nursingservices” as well as for essential med-ical services.

In response to requests for guidance onself-employment received from nursesacross the country, CNA has preparedthis resource to answer some frequentlyasked questions about entrepreneurialnursing practice.

Who are nurseentrepreneurs?Nurse entrepreneurs are proprietors ofbusinesses offering nursing services inadvocacy, health promotion, direct care,education, research, admin-istration or consultation.2

They provide nursing ser-vices themselves or employothers to do so. Describedas being in “independent”or “private” practice or “self-employed”, these nurseentrepreneurs are directlyaccountable to the client.

Their clients areindividuals, families,communities, educationalinstitutions, governmentdepartments, health carefacilities and agencies, pri-vate businesses, churchgroups and non-profit organizations.

Is self-employment in nurs-ing something new?Not at all. In the early years of this cen-tury, most nurses were independentpractitioners, engaged by families toprovide nursing services in their homes.In the 1930s, 60 per cent of all regis-

tered nurses in Canada were self-employed private duty nurses.3

Following the Second World War, social,economic and technological changesresulted in a reorganization of nursingpractice. The delivery of nursing servicesmoved from the home to the hospitaland most nurses became employees.

What has renewed nurses’interest in self-employment?Changes in nursing and health care havecreated new opportunities. There is agreater diversity in nurses’ roles and sig-nificant advances in nursing knowledgeand education have taken place. Excited

by the prospect of prac-tising to their full scopeand tailoring their ser-vices to meet specificclient needs, a growingnumber of nurses havechosen to establish theirown businesses.Necessity acceleratedthis trend as nurses lostjobs through hospitalrestructuring.

Health care has alsochanged. Today, greateremphasis is placed onhealth promotion, ill-ness and accident pre-

vention, rehabilitation and support ser-vices. More consumers are betterinformed about their health needs andthey wish to choose their own provider.4

How does this trend fit withCNA’s vision of nursing? In CNA’s vision of the profession, nursesare committed to the public interest andto excellence in client-centred care. As an

On Your Own – The NurseEntrepreneur

SEPTEMBER 1996 NUMBER ONE

Nurses,individually andas a profession,must lobby to

increaserecognition ofthe value of

nursing servicesso that theseservices will

become part ofthe publicly

funded system.

50 DRIVEWAY, OTTAWA, ON K2P 1E2

TEL: (613) 237-2133 1-800-361-8404 FAX: (613) 237-3520 E-MAIL: [email protected]

access point to the health care system,nurses assess, admit and discharge clientsfrom health services, provide a wide rangeof nursing interventions and supportclients along a continuum of care.5

Many nurses believe that they can bestfulfill this vision by providing their ser-vices independently. The need existsand nurses have the expertise to offer.

To be completely accessible, health carehas to be affordable. Since governmentsdo not reimburse nurses through provin-cial or territorial health insurance plans,most self-employed nurses are paiddirectly by their clients. Some are reim-bursed through private insurance carriedby the client. This reduces access tonursing services. Nurses, individually andas a profession, must lobby to increaserecognition of the value of nursing ser-vices so that these services will becomepart of the publicly funded system.

What services are nurseentrepreneurs offering?Nurses offer a broad range of innovativeservices in a variety of settings. Manyservices provide direct care such as sup-porting breast-feeding mothers,enterostomal therapy, family coun-selling, holistic nursing with comple-mentary modalities, health promotionservices such as stress managementand occupational health nursing ser-vices. Nurses provide advocacy andorganize support services for clientswith chronic problems. Some nursesoffer continuing education to employ-ees of health care facilities. Others pro-vide administrative services such asquality monitoring to health care facili-ties and agencies. These are just a fewexamples. Nurses will continue todevelop creative solutions to meet thechanging health needs of Canadians.

Is self-employment for you?Self-employed nurses talk about the per-sonal satisfaction and sense of achieve-ment that comes with being an entrepre-neur, although at times they have to livewith financial uncertainty and perhapsdiminished income. The Gage CanadianDictionary describes an entrepreneur assomeone “attempting to make a profit,but taking the risk of a loss.”

They stress the impor-tance of planning andgood advice, keeping inmind that self-employednurses assume many ofthe responsibilities ofemployers in traditionalsettings. If you are con-templating self-employ-ment, both professional(nursing) and businessissues need to be con-sidered. Although theyare presented separatelybelow, the boundaries between the twoparts of your practice are not necessari-ly so clearly defined.

PROFESSIONALCONSIDERATIONSHow do I choose the ser-vices I will offer? Assessment is always the first step!You have the best chance of success ifyou identify a need for your servicesand work with the community to meetthose needs. Explore avenues of fund-ing and agencies that might supportyour services.

Is the service I’m planningnursing?Self-employed nurses are legally per-mitted to offer any service that fallswithin the practice of nursing and doesnot infringe on the legislated responsi-bility or the exclusive practice of anoth-er health discipline. The practice ofnursing is guided by standards deter-mined by your nursing regulatory body.6

Legal definitions of nursing are general-ly very broad. It’s not always easy todetermine whether the service youintend to provide falls within the scopeof nursing practice. The key question toask yourself is: does the service beingprovided require the application ofprofessional nursing knowledge? Aservice cannot be considered nursingsolely because a registered nurse per-forms it. The determining factor is therequirement for professional nursingknowledge. A review of nursing curricu-la and literature can also help youdecide whether nursing education is a

prerequisite for the per-formance of yourplanned service.

With the evolution andexpansion of nursingpractice, it is alsoimportant to reviewprovincial or territoriallegislation regulatingthe practice of otherhealth disciplines suchas medicine, pharmacy,podiatry and psychology

to determine that the service you planto provide is not the exclusive practiceof another discipline. Many competen-cies, such as counselling, are shared byseveral health professions. Others,such as the diagnosis and treatment ofdisease, are unique to medicine.

In some Canadian jurisdictions, nursesmust accumulate a designated number ofhours of practice to renew their nursingregistration/license. Since self-employednurses achieve this within their business,it is critical that the service they are pro-viding be defined as nursing.

What qualifications do I needto be a nurse entrepreneur? You must be currently registered withyour regulatory body as a practisingmember and have:

• appropriate education and experienceto practise competently within yourchosen area of nursing expertise;

• knowledge and skill in the nursingservices you provide;

• ability to manage the outcomes ofyour assessment;

• consultation and communication skillsso you can develop and maintain referral mechanisms with other healthcare providers; and,

• marketing and management skills toconduct the business aspects ofpractice.

Self-employed nurses often have feweropportunities for nursing consultationand supervision than nurses who areemployees in health care facilities andagencies. Therefore, you need to havesufficient educational preparation and

CANADIAN NURSES ASSOCIATION • ASSOCIATION DES INFIRMIÈRES ET INFIRMIERS DU CANADA

50 DRIVEWAY, OTTAWA, ON K2P 1E2 TEL: (613) 237-2133 1-800-361-8404 FAX: (613) 237-3520 E-MAIL: [email protected]

Nurses willcontinue to

develop creativesolutions to

meet thechanging health

needs ofCanadians.

experience both for the services thatyou will provide and to manage theindependent aspects of your practice.

To whom am I accountableand how do I demonstratemy accountability?As a member of a self-regulating profes-sion, you are accountable to your clientsand your professional regulatory body.In certain situations you may also beaccountable to a third party (e.g., ahealth care agency) which has contractedyou to provide nursing services.

All nurses are guided by:

• nursing legislation;

• provincial/territorial standards ofnursing practice; and,

• the CNA Code of Ethics for Nursing.

In addition, nurses who practise in a spe-cialty are guided by specialty standards.

Should I have a writtendescription of my practice?You should describe the scope of yourintended services in a way that clearlyspecifies it is an independent nursingpractice. You will also need to describeyour arrangements for such things as:

• obtaining informed consent to treat-ment;

• agreements with your clients for ser-vices provided (e.g., verbal agreement,written contract);

• payment mechanisms;

• referral to other healthcare providers, healthcare facilities and agen-cies, and mechanismsfor sharing information;

• your record keepingsystem;

• assessing your nursingcompetency, acknowl-edging limitations andarranging for upgrad-ing of knowledge andskills, as required; and,

• systematic evaluationof the practice such ason-going quality moni-toring and peer review.

What are some otherprofessional considerationsin managing my practice?Client records

In documenting your nursing services,consider relevant provincial/territoriallegislation and standards or guidelinesfor documentation prepared by yournursing regulatory body. Plan for:

• the charting system for nursingassessment, plans, intervention andclient response;

• security of confidential information;

• consent for release of information;and,

• storage, retention and destruction ofrecords.

Marketing your nursing services

Marketing is key to the success of yourbusiness. You can use various marketingstrategies including business cards,brochures, advertisements in newspa-pers and radio and television interviews.The service must be represented clearlyand fairly. You may wish to register yourbusiness name, so choose it carefully.

Review guidelines concerning advertisingnursing services prepared by your regula-tory body and consult with their nursingpractice personnel. Consider consultinga lawyer, too. In particular, be aware ofany potential conflict of interest or

restrictions regarding theuse of the registerednurse title, solicitation ofclients and endorsementof products.

Setting appropriate fees

You are financiallyresponsible for yourpractice. Currently, avariety of client billingmethods are used,including hourly, dailyor sessional rates, slid-ing scale payments andfixed price contracts.Nurses are exploringways to sell their ser-vices to a “community”(e.g., a community

council or seniors residence). Manynurses find it difficult to determine howmuch to charge for nursing services.Your fee should reflect the scope andcomplexity of the service provided.Your clients need to be clear aboutwhat services you are providing for thefee.

In establishing your fee structure:

• find out what clients are paying forsimilar services and what other nursesare charging;

• seek the advice of an accountant andother financial consultants; and,

• factor in your costs (e.g., travel, equip-ment) and desired profit.

Liability protection

Self-employed nurses who are mem-bers in good standing with participat-ing professional associations are eligi-ble for professional liability protectionfrom the Canadian Nurses ProtectiveSociety (CNPS) for incidents that ariseout of the provision of professionalnursing services. This is another rea-son why it is so important to be clearthat the service you are providing is anursing service. Some nurses are regis-tered in more than one discipline (e.g.,midwifery, massage therapy) and mustclarify the impact of dual registrationon liability protection. Contact CNPS at1-800- 267-3390 to discuss liabilityissues and refer to CNPS’s Infolaw;Independent practice: Legal considerations.

If you employ others, you needemployer liability protection. This pro-tection is not available from CNPS.Contact an insurance broker to arrangeappropriate coverage.

BUSINESSCONSIDERATIONSAn independent nursing practice is abusiness. You need to start with a busi-ness plan. Although planning and man-aging your business will likely presentmany challenges, several resources areavailable to assist you.

Familiarize yourself with legislationpertinent to small business. Contact

You need to havesufficient

educationalpreparation andexperience bothfor the services

that you willprovide and to

manage theindependent

aspects of yourpractice.



your provincial/territorial associationfor names of lawyers, accountants, con-sultants and insurance brokers whospecialize in small business to helpyou. They can also review your busi-ness plan, and provide advice on mat-ters such as the optimal structure forbusiness, records andinsurance. Thesebusiness considera-tions are summarizedbriefly here.

Business planOutline your goalsand objectives, andidentify the marketand marketing strate-gies. Include a finan-cial forecast for yourbusiness and deter-mine any financingrequirements. Somemunicipalities requirethat you hold a business license.

Business structureYour practice can be structured in variousways including: sole proprietorship,partnership or group practice or, in someprovinces, incorporation as a limitedcompany. Obtain legal and accountingadvice to determine which structure ismost suitable.

Business recordsIn addition to client records, you mustkeep business records. Consult anaccountant to establish good recordkeeping practices related to billing sys-tems, client accounts and the filing oftax forms (e.g., income tax, goods andservices tax). Consult regional districttaxation offices of Revenue Canada.

Business insuranceBusiness insurance needs vary greatlyaccording to the type of servicesoffered, location and number ofemployees. Consult an insurance bro-ker and provincial/territorial workers’compensation boards.

RESOURCESFOR NURSESCONSIDERINGENTREPRE-NEURIALNURSINGPRACTICEBefore establishing your-self as a self-employednurse, you will need tocarefully research theprofessional and business

issues identified above and elsewhere.While valuing the independence thatcomes with self-employment, you mayat times feel isolated and lack opportu-nities for mutual support and relevanteducation. The resources listed belowwill help you with your research andlead you to sources of personal sup-port and education.

Consult your provincial/territorialnursing association. Nursing practiceand education consultants, and theregistrar can provide you with prac-tice standards, advice, position state-ments and guidelines.

Network with other nurse entrepre-neurs. Sharing information and ser-vices will help you to identify commu-

nity needs and a collaborative net-work for referrals.

The Canadian Association of Nursesin Independent Practice (CANIP) isan interest group of CNA. CANIPhas prepared Guidelines for IndependentNursing Practice and maintains anational directory of nurses in inde-pendent practice. Membership pro-vides you with a network and sup-port group of self-employed nurses,information and educational oppor-tunities and a forum for lobbying.CANIP’s mailing address is: 55McCaul Street, Box 155, Toronto, ONM5T 2W7.

Educational courses and workshopsthat combine both the professionaland business issues of practice areincreasingly being offered. Contactnursing organizations and your localuniversity or community college forinformation.

Midland Walwyn Capital Inc. providesCNA’s Retirement & Savings Programand offers financial services, includingno-charge financial planning to CNAmembers. Call the CNA InvestorServices Hotline at 1-800-563-6623 forinformation.

Contact nursing libraries — such asCNA’s Helen K. Mussallem Library (E-mail: [email protected]) —for literature under headings suchas entrepreneurship and privatepractice.

1 Subsequent use of “nurse” refers to registered nurse.2 International Council of Nurses (1994). Guidelines on the nurse entrepreneur providing nursing service.

Geneva: Author, p. 5.3 Baumgart, A.J. & Wheeler, M.M. (1992). The nursing work force in Canada. In A.J. Baumgart & J. Larsen (Eds.),

Canadian nursing faces the future (pp. 45-69). Scarborough: Mosby-Year Book Inc., p. 56.4 International Council of Nurses (1994). , pp. 7-8.5 Canadian Nurses Association (1995). Vision statement: CNA’s vision of nursing. Ottawa: Author.6 In Canada nursing is regulated by professional legislation that defines, describes and controls the practice of

nursing. As a self-regulating profession, the responsibility for regulation is usually granted to a professionalbody by the legislation. This responsibility usually rests with the provincial or territorial nursing association,although in Ontario, there is a separate college for this purpose. The nursing regulatory bodies specify thedetails of how legislation is applied. (Canadian Nurses Association [1993]. The scope of nursing practice: Areview of issues and trends. Ottawa: Author, pp. 10-12.)



Nursing Now is a series of short papers that

explore issues and trends in Canadian

Nursing. This is the first in the series.

Nursing Now is published by the Nursing

and Health Policy Division of the Canadian

Nurses Association (CNA).

Copies are available free to all CNA

members. For additional information

and/or additional copies contact CNA

Publications.

BusinessConsiderations

BusinessPlan

BusinessStructure

BusinessRecords

BusinessInsurance

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ownentrepreneur sept1996 e

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