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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

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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.

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...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

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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

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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).

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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

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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).

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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

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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

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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:anne.wilson@adelaide.edu.au

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

NancyWhitaker,BA(Hons),MPsychEmail:nancy.whitaker@adelaide.edu.au

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

DeirdreWhitford,PhDEmail:dwhitford01@bigpond.com

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

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