INDEPENDENT NURSE PRACTICE

Introduction

Independent Nurse Practitioners (INPs) are uniquely qualified with advanced practice skills to
meet the increased demand for primary care services.

Nurse Practitioners have demonstrated the ability to provide care to many underserved groups,
such as children, women, migrant workers, the homeless, and the elderly in non traditional
settings, such as schools, work sites, and health departments. Although multiple studies have
documented the high quality of care and cost-effectiveness of APNs, these nurses remain an
under-utilized resource.

Independent/Advanced Practice Nurse

The advanced practice nurse is a registered nurse who has acquired the expert knowledge base,
complex decision making skills and clinical competencies for expanded practice, the
characteristic of which are shaped by the context and/or country in which he/she is credentialed
to practice.

Advanced Practice Nurse (APNs) include registered professional nurses, with a current license to
practice, who is prepared for advanced nursing practice by virtue of knowledge and skills
obtained through a post-basic or advanced education program of study acceptable to the State
Board of Nurse Examiners. The APN is prepared to practice in an expanded role to provide
health care to individuals, families, and/or groups in a variety of settings including, but not
limited to, homes, hospitals, institutions, offices, industry, schools, community agencies, public
and private clinics, and private practice. The APN acts independently and/or in collaboration
with other health care professionals to deliver health care services (Texas Nurse Practice Act,
Section 221). APNs conduct comprehensive health assessments aimed at health promotion and
disease prevention. They also diagnose and manage common acute illnesses, with referral as
appropriate, and manage stable chronic conditions in a variety of settings. APNs titles include
Nurse Practitioner, Clinical Nurse Specialist, Certified Nurse Midwife, and Certified Nurse
Anesthetist. Independent practitioners are capable of solo practice with clinically competent
skills and are legally approved to provide a defined set of services without assistance or
supervision of another professional.

APNs are uniquely qualified to resolve unmet needs in primary health care by serving as an
individual’s point of first contact with the health care system. This contact provides a
personalized, client-oriented, comprehensive continuum of care and integrates all other aspects
of health care over a period of time. Care should be provided as much as possible by the same
health care professional, with referrals coordinated as appropriate. The focus of care is on health
surveillance (promotion and maintenance of wellness), but it also provides for management of
acute and stable chronic illness in order to maintain continuity.

INP history and development

The INP role originated as one strategy to increase access to primary care in response to a
shortage of primary care physicians. The first successful program to prepare NPs was developed
at the University of Colorado in 1965 under the co-direction of a nurse, Loretta Ford, and a
physician, Henry Silver to prepare pediatric NPs with a focus on health and wellness. Working
collaboratively with physicians, NPs with this advanced education from non-degree, certificate
programs, were able to identify symptoms and to diagnose and manage health problems in
children.

Federal legislation in the mid 1960’s provided funding to support the development of primary
care providers. In 1971, the Secretary of Health, Education and Welfare issued primary care
intervention recommendations for which nurses and physicians could share responsibility, thus
implying support for nurses as primary care providers.

With the support of federal monies, nursing programs for NPs multiplied. By the mid-1970’s,
there were more than 500, mostly certificate, programs across the country that were preparing
nurses to deliver primary care. Programs gradually shifted from certificate to master’s degree
preparation as accrediting bodies increasingly required a master’s degree. By the 1980’s,
master’s degree programs far outweighed certificate programs. In response to health care reform
in the 1990’s, NP programs are proliferating at an astonishing rate to meet increasing demands
for primary care services. As of 1995, 248 programs in the U.S. offer a master’s degree with
preparation as a NP. In 1994, 49,000 nurses were employed as NPs.

In 1974, the American Nurses Association published educational guidelines for the preparation
of NPs and implemented a credentialing program in 1976 that still exists. Other specialty nursing
organizations have likewise approved credentialing requirements. In many states, this
certification is required for licensure as a NP.

Data in Table 1 show the current credentialing organization for NPs.

Table 1: Current Nurse Practitioner Credentialing Organizations

Recent increases in the numbers of new NP programs have generated concern regarding quality
and effectiveness of NP preparation. For instance in 1994, The Texas Higher Education
Coordinating Board and the Board of Nurse Examiners for the State of Texas studied the
standard curriculum requirements for advanced practice designation. In addition to research and
theory courses, the curriculum for APNs typically include advanced physiology, pharmacology,
and clinical practice emphasizing a selected role. Preceptorships in an appropriate clinical area
are a vital part of the educational process. The changes made in Texas strengthened the content
requirements for advanced courses in health assessment, pathophysiology, pharmaco-
therapeutics, practice role, and preceptorship. Additionally, to address quality issues and
strengthen the practice role, educators are standardizing nurse practitioner curricula across the
state and are working collaboratively with new initiatives to meet the increasing need for NPs.
Clearly, excellence in educational standards is a key to public acceptance and professional
effectiveness.

Unique Aspects of an Independent Nursing Practice

Business start-up can be an anxiety-producing time for any business owner. Creating an
independent nursing practice has additional unique considerations. Scope of practice varies from
state-to-state. Know your state laws and the extent of any collaborative or supervisory provision.
Prescriptive authority also varies between states and may or may not include some aspect of
prescribing scheduled drugs.

Healthcare services by an NP may be reimbursed from third-party payers at a lower rate or not at
all. Managed care may be pervasive in your geographic area and may limit or deny access to
managed care panels for NPs.

Although your practice may manage clients with acute and chronic illness, you must determine
how to provide 24 hour coverage for emergencies and handle clients who are hospitalized. Even
if your clients are covered by a hospitalist as an inpatient, you may have to apply for hospital
privileges to provide healthcare or counseling to your client prior to discharge.

Scope of Independent nursing practice

A major question to consider is the scope of independent NP practice in the state in which you
practice. Forty states currently have statutory or regulatory requirements for physician
collaboration, direction, or supervision. However, only eleven states (including the District of
Columbia) have independent prescriptive authority that does not require physician involvement
or delegation. If your practice is not located in one of these enlightened states, carefully read and
clarify the policies regarding collaboration or supervision of your practice and the regulation of
your prescriptive authority. Developing a collaborative agreement with a physician and creating
appropriate protocols, including protocols for controlled substances, are other areas to investigate
if this is a state requirement for NP practice.

Reimbursement is another major question to consider. Investigate how pervasive managed care
is in your practice location and determine if NPs are admitted to managed care panels and listed
as primary care providers. Investigate the area hospitals to determine if NPs are given hospital
privileges. Even if NPs are admitted to hospital panels in your area, you will need a collaborative
arrangement or referral agreement with various physicians in the area for management of your
patients when they are acutely ill

Advantages to Independent Practice

Independent practice provides the opportunity to specialize and maximize the care of the client
as well as the time to provide the educational base necessary to enable the client to become a true
partner in the healthcare regimen. Independent practice affords NPs the ability to focus their
energy on an area of interest such as women's health or alternative therapy. A flexible workload
allows time to focus on client needs and deliver much-needed education and preventive
healthcare.

Independent practice must be sustainable, and a focus on payment for services can utilize a
variety of sources. Beside third-party reimbursement, contracts for service can be sought in
industry and community groups. Income can be tied to workload for professional employees and
as new opportunities and requests for service increase, expansion of services and practice growth
will expand revenues

As an independent healthcare provider, you will be responsible for staffing. This provides an
opportunity to work with people you respect and who share your philosophy of healthcare.
Independent practice enhances problem-solving skills and self esteem and provides the
opportunity to constructively deal with change, resolve conflicts and implement strategies to
create a profitable practice.

Barriers to Independent Practice

Nurse practitioners have long been lauded in the literature with respect to the high quality of
patient care and cost-effectiveness. Their practice has been compared to physicians in primary
care practices and findings suggest that NPs provide comparable high-quality care with similar
positive health outcomes. What barriers to practice are so prevalent that they dissuade this
competent, highly educated and cost-effective group of healthcare providers from establishing
independent practices?

Safriet (1992) identified three major barriers to practice: the lack of third-party reimbursement,
prescriptive authority, and hospital admission privileges. Without third-party reimbursement to
ensure a financial base, NPs are unable to provide direct services for the care they provide.
Instead, cost increases are generated by supervision requirements, complex billing services, and
lack of autonomy in decision-making. When NPs are unable to prescribe medications for client
needs, there can be a delay in treatment. Otherwise, sophisticated systems are required to provide
for prescription disbursements such as pre-signed prescription pads, call-in services, and
prescription writing by other providers who have not themselves assessed the client’s needs.
When NPs are not allowed to admit their clients to the hospital, follow them during their stay,
nor obtain referral information when clients are discharged, the concept of primary care services
is altered. A multi-tiered system results, in which the client encounters delay and lack of follow
up. These barriers hinder autonomous and holistic health care practice, both in a collaborative
practice based on a team approach and in independent health care practice

Nationally, Pearson identifies four major roadblocks to independent NP practice as direct

reimbursement from third-party payers, statutory limitations to NP scope of practice, inconsistent
and restrictive prescriptive authority and denial of hospital privileges. Historically, physicians
were the first healthcare providers granted legislative autonomy. This autonomy and recognition
enhanced the public's confidence that the actions of physicians were always directed for the good
of the public and not for personal gain. Financial security, legislative strength and a unified
medical community also play a role in organized medicine's control of hospital policy and third-
party reimbursement.

Additionally, common problems applicable to most new start-up businesses contribute to the
dearth of independent NP practices. Major obstacles to overcome with the start of most new
businesses include start-up costs, cash-flow and collection of receipts in an ongoing practice,
practice management issues including city, state and federal regulations, high costs of insurance,
and managing personnel. The obstacles inherent in starting a business coupled with the unique
barriers confronting independent NP practice have provided a challenge to many individuals.

Key practice components

Conflict of interest
A nurse’s primary obligation is providing professional care to her/his clients. Nurses are in a
position of trust and cannot use their position to influence their clients for financial gain (for
example, by selling products) or non-financial benefit (for example, by soliciting money for
fundraising purposes). Nurses should avoid promoting personal interests, such as selling
products or services, to clients they are treating. Selling products may give the appearance of
fulfilling the nurse’s personal interests over the client’s needs. It is critical that nurses in
independent practice avoid conflict of interest situations in their practice, particularly when it
comes to the endorsement and advertising of products.

Fees
The following activities related to fees are considered professional misconduct:
■ submitting an account or charge for services that the member knows is false or misleading;
■ failing to fulfil the terms of an agreement for professional services;
■ charging a fee that is excessive in relation to the services for which it is charged; and/or
■ offering or giving a reduction for prompt payment of an account.
Before setting fees, a nurse should research the fees of other nurses who have similar
qualifications and experience, and who provide comparable services.

Informed consent
Nurses in independent practice are expected to obtain informed consent before performing any
treatment. For consent to be valid, it must relate directly to the treatment. Treatment is defined as
anything that is performed for a therapeutic, preventive, palliative, diagnostic, cosmetic or other
health-related purpose, and includes a course or plan of treatment. For more information, refer to
the College’s Consent practice guideline.
Documentation
An integral part of the service that a nurse provides is creating and maintaining accurate and
complete health records and documentation. Health records are the means by which information
about the client is communicated to the health care team and how continuity of care is
maintained. They also demonstrate the nurse’s accountability and answer questions about the
type of care provided.

Confidentiality
Nurses in independent practice are required to maintain the confidentially of client information
and cannot communicate the information to another person unless the client or client’s
representative gives consent or it is required by law.

Endorsement
Endorsing or promoting a product or service is closely linked to conflict of interest. It may be
considered a conflict of interest, and therefore professional misconduct, for a nurse to use her/his
registration status to promote a personal interest in a commercial product or service.
Endorsement occurs when a nurse uses her/his credentials to lend credibility to a commercial
product, product line or service. A nurse cannot use her/his registration as an RN, RPN or NP to
lead the public to believe she/he knows that one product is better than another, even if she/he
believes it to be true. The endorsement of a product or service without providing information
about other options could mislead the public and compromise trust.

Advertising
There are limitations on how a nurse can advertise her/his services. The public should be given
relevant information, the advertising doesn’t mislead the public and the public’s trust in the
nursing profession is maintained. The content in advertisements must be accurate, factual and
verifiable, and must include a nurse’s name and category of registration (RN, RPN or NP) as it
appears on the College’s Register. Advertising may take various forms, such as business cards,
listings in telephone directories, announcements in newspapers and periodicals, and promotional
materials. It can include information such as a description of services and nursing credentials,
practice experience, fees, address and phone number. However, unsolicited testimonials,
references to guarantees, comparative or superlative statements, and sensational advertising
should be avoided, as should promotional devices such as premium offers, giveaways, discounts
and coupons.

Other issues
Incorporation
Regulated professionals may incorporate their independent practice under legislation.

Business/legal counsel
Nurses may want to seek legal advice before starting an independent nursing practice.

Liability protection
The nurses in independent practice purchase liability protection to enable public redress should
any problems occur.

Networking
Entrepreneurial/support groups for self-employed nurses offer assistance with peer feedback,
idea and issue sharing, planning for vacation and sickness, etc.

NURSE PRACTITIONERS

Definition

A Nurse Practitioner (NP) is an Advanced Practice Nurse (APN) who has completed graduate-
level education (either a Master's or a Doctoral degree). Certified Registered Nurse Anesthetist
(CRNA)s, CNMs, and CNSs are additional APN roles. All advanced practice nurses are
Registered Nurses with additional education and training. To become licensed to practice, Nurse
Practitioners hold national certification in an area of specialty (family, women's health,
pediatrics, adult, acute care, etc.), and are licensed through state nursing boards rather than
medical boards. The core philosophy of the field is individualized care. Nurse practitioners focus
on patients' conditions as well as the effects of illness on the lives of the patients and their
families. NPs make prevention, wellness, and patient education priorities. Another focus is
educating patients about their health and encouraging them to make healthy choices. In addition
to health care services, NPs conduct research and are often active in patient advocacy activities.

Nurse Practitioners treat both physical and mental conditions through comprehensive history
taking, physical exams, physical therapy, and ordering tests and therapies for patients within
their scope of practice. NPs can serve as a patient's primary health care provider, and see patients
of all ages depending on their designated scope of practice.

Education, licensing, and board certification

To be licensed as a nurse practitioner, the candidate must first complete the education and
training necessary to be a registered nurse (RN).

Once registered nurse status is attained, the candidate must complete a state-approved advanced
training program that usually specializes in a field such as family practice, internal medicine, or
women's health. The degree can be granted by any of the following:

 Community college (grants an associate degree)

 Hospital-based program (grants a 3-year diploma)
 University, which grants a bachelor of science in nursing (BSN) degree; a master's of
science in nursing (MSN) degree, which is the minimum degree required; or a doctorate
in nursing

After completing the education program, the candidate must be licensed by the state in which he
or she plans to practice. The State Boards of Nursing regulate nurse practitioners and each state
has its own licensing and certification criteria.

After receiving state licensing, a nurse practitioner can apply for national certification from the
ANA or other professional nursing boards such as the American Academy of Nurse Practitioners
(AANP). Some NPs pursue certification in a specialty.
In the United States, nurse practitioners have a national board certification. Nurse Practitioners
can be trained and nationally certified in areas of Family Health (FNP), Pediatrics, including
Pediatric Acute/Chronic Care, Pediatric Critical Care, Pediatric Oncology and general Pediatrics
(PNP), Neonatology (NNP), Gerontology (GNP), Women's Health (WHNP), Psychiatry &
Mental Health (PMHNP), Acute Care (ACNP), Adult Health (ANP), Oncology (ONP),
Emergency (as FNP or ACNP), Occupational Health (as ANP), etc. In Canada, NPs are licensed
by the province or territory in which they practice.

Scope of practice

In the United States, because the profession is state-regulated, care provided by NPs varies
widely. Some nurse practitioners work independently of physicians while, in other states, a
collaborative agreement with a physician is required for practice. The extent of this collaborative
agreement, and the role, duties, responsibilities, medical treatments, pharmacologic
prescriptions, etc. afford an NP to perform and prescribe again varies widely amongst states of
licensure practice.

A nurse practitioner's role may include the following:

 Diagnosing, treating, evaluating and managing acute and chronic illness and disease (e.g.
diabetes, high blood pressure)
 Obtaining medical histories and conducting physical examinations
 Ordering, performing, and interpreting diagnostic studies (e.g., routine lab tests, bone x-
rays, EKGs)
 Prescribing physical therapy and other rehabilitation treatments
 Prescribing drugs for acute and chronic illness (extent of prescriptive authority varies by
state regulations)
 Providing prenatal care and family planning services
 Providing well-child care, including screening and immunizations
 Providing primary and specialty care services, health-maintenance care for adults,
including annual physicals
 Providing care for patients in acute and critical care settings
  Performing or assisting in minor surgeries and procedures (with additional training and/or
under physician supervision in states where mandated; e.g. dermatological biopsies,
suturing, casting)
 Counseling and educating patients on health behaviors, self-care skills, and treatment
options

Practice settings

NPs practice in all U.S. states, Canadian provinces and territories and in all Australian states and
territories. The institutions in which they work may include:

 Community clinics, health centers, urgent care centers

 Health departments
 Health maintenance organizations (HMOs)
 Home health care agencies
 Hospitals and hospital clinics
 Hospice care
 Nurse practitioner practices/offices
 Nursing homes
 Nursing schools
 Private & public schools, universities and colleges
 Physician/private medical practices
 Physician offices
 Veteran's administration facilities
 Retail-based clinics
 Public health departments
 School/college clinics
 Veterans Administration facilities
 Walk-in clinics

Specialisations in nurse practitioner

 1. Adult nurse practitioner

ANP provides primary ambulatory care to adults with non emergent acute or chronic illnesses
and in some settings, tertiary care. ANP’s work collaborately with one or more primary care
physicians, for example, in five physician primary care practice, a nurse practitioner may
exclusively manage all diabetic clients who have foot ulcer. In this example, a nurse practitioner
work in collaboration with all physicians.

2. Family nurse practitioner

A family nurse practitioner provides primary ambulatory care for families, usually in
collaboration with family care physician. The FNP manages family’s general health care needs,
manages illness by providing direct care and guides or counsels the family as needed.

3. Paediatric nurse practitioner

The paediatric nurse practitioner provides health care to infants and children. PNPs practice in
hospitals, ambulatory care, emergency care and physician’s offices.

3. Woman’s health nurse practitioner

A woman’s health nurse practitioner provides primary ambulatory care to women seeking
obstetrical and gynaecological health care.

4. Acute care nurse practitioner

An acute care nurse practitioner functions in collaboration with a physician or house staff
physician in an acute care setting such as a hospital or speciality clinic. The acute care nurse
practitioner is a generalist, usually based on internal medicine focusing on care of the
hospitalised patient.

4. Geriatric nurse practitioner

A GNP has specialization in care of older adults. GNPs are trained in the special needs of aging
adults with an emphasis on health promotion, health maintenance and functional status. The
GNP works with the client and family to manage existing health problems so as to promote
independence and health care. The client population is usually age 65 and older.

CLINICAL NURSE SPECIALIST

Definition

Clinical Nurse Specialists (CNS) are licensed registered nurses who have advanced study
(Master’s or Doctorate degree) in nursing. Clinical Nurse Specialists are expert clinicians in a
specialized area of nursing practice. They have a variety of skills to help you deal with your
illness and work with your health care team members to provide personalized nursing care.

Clinical Nurse Specialist Certification

In order to be eligible to be certified as a CNS, an RN must have completed an accredited

advance practice nursing program, and a minimum of 500 hours of clinical experience
concurrently with Master’s level course work in the five component areas of competency. This
course work may be completed at any nationally accredited master’s/post-master’s nursing
academic program.

There are five major components of the CNS role. Activities within these role components may
include the following:

Expert Clinical Practice

1. Works with staff to improve clinical care.
2. Uses advanced theoretical and empirical knowledge of physiology, pathophysiology,
pharmacology, and health assessment.
3. Assesses and intervenes in complex health care problems within a selected clinical specialty
area and selects, uses, and/or evaluates technology, products, and devices appropriate to the
specialty area of practice.
4. Manages populations of clients with disease states and non-disease based etiologies to
improve and to promote health care outcomes.
5. Precepts students and mentors other nursing staff.

Education
1. Assists with and promotes staff development.
2. Provides formal education classes (i.e., community education and/or presentations) and
informal education classes (i.e., in-services).
3. Serves as a preceptor to nursing students, new RN graduates, RNs reentering the workforce,
and advanced practice RN students and RNs.
4. Mentors and coaches staff and students.

Research
1. Uses clinical inquiry and research in an advanced specialty area of practice.
2. Uses a performance improvement model as an avenue to improve advanced clinical practice
and care.
3. Stays abreast of current literature in the specialty area of practice.
4. Initiates research into topics that directly impact nursing care and uses measurement and
evaluation methodologies to assess outcomes.
5. Publishes data from research topics related to the specialty area of practice.

Consultation
1. Performs consultative functions in multiple health care settings.
2. Provides clinical expertise and makes recommendations to physicians, other health care
providers, insurance companies, patients, and health care organizations.
3. Reviews standards of practice to determine appropriateness and to reflect current nursing
clinical practice.
4. Evaluates policy and procedures for clinical practice in a specialty area.
5. Uses evidence-based clinical practice to develop methods to improve patient care and patient
care outcomes.

Clinical Leadership
1. Uses theory/research as a foundation for clinical leadership and CNS research based practice.
2. Demonstrates mastery in theories including Change Theory, Persuasion, Influence, and
Negotiation Theory, Systems Theory, Consultation Theory, Research Theory, and Research
Utilization.
3. Participates in the professional development of self, others, and the nursing profession.
4. Belongs to and participates in professional organizations.
5. Serves as a change agent in health care settings by developing health care standards, assisting
in the implementation of standards, facilitating goal setting and achievement, and evaluating
outcomes.
6. Serves in a leadership role in the community.

CERTIFIED NURSE ANESTHETIST

Definition

Certified Registered Nurse Anesthetists (CRNAs) represent a long-standing commitment to high

standards in a demanding field. They provide one-on-one care to their patients before, during,
and after the operation by delivering quality anesthesia services for surgical and obstetrical
procedures combined with a personal concern for the health and welfare of the individual.

An estimated 20 million anesthetics are given in the United States each year, and CRNAs
administer more than half of them in a variety of procedures, including obstetric, pediatric,
neurosurgical, and cardiovascular, all with a high rate of success.

Practice settings
CRNAs may practice in a number of settings in addition to the operating room. They may
provide anesthesia in emergency rooms or intensive care areas. Nurse anesthetists may also be
employed by dentists, dental specialists, podiatrists, plastic surgeons, and by the increasingly
common ambulatory surgical centers, health maintenance organizations (HMOs), preferred
provider organizations (PPOs), other alternative care facilities, or be self employed.

In urban areas, CRNAs constitute approximately half of the professionals qualified to \

administer anesthesia; in rural settings, this percentage increases. Currently, 42% of all CRNAs
are employed by hospitals and 35% by physicians, while 13% contract their services
independently, all working in a variety of practice settings. Still others serve the U.S. military
and Veterans Administration system (10%).

Educational qualification

Applicants for nurse anesthetist training must first have a bachelor's degree in registered
nursing. Nurse anesthetist training is provided by both hospitals and universities, and a master's
degree is awarded after completing 24-36 months course work and at least 800 hours of clinical
experience. The length of the nurse anesthesia program varies according to institution,
depending upon the type of degree offered. The foundation of the specialty of nurse anesthesia is
professional nursing and the basic sciences.

Nurse anesthetists must also pass a national certification examination before they are allowed to
practice.

Duties and Responsibilities

A nurse anesthetist is an advanced practice registered nurse who has had special educational
training in administering anesthesia. Duties include administering anesthesia to those being
operated on in hospitals and keeping constant watch on the patients' vital signs. Additionally,
nurse anesthetists may advise and help treat patients with cardiopulmonary and respiratory
conditions. Nurse anesthetists usually work in hospitals, psychiatric institutions, or dental
offices.
 THE CERTIFIED NURSE-MIDWIFE

Definition of a Certified Nurse-Midwife

A certified nurse-midwife is an individual educated and licensed in the disciplines of registered

nursing and nurse-midwifery who possesses evidence of certification issued by the Board of
Registered Nursing.

Historical development

Although midwifery remained a part of mainstream healthcare in many parts of the world, the
renaissance of midwifery in the United States was not to occur until the 1940s to 1950s. Strong
nursing leaders and the child birth education movement largely shaped the reappearance of
midwifery as a nursing role. Like other forms of advanced practice nursing , that emerged much
later, the resurgence of midwifery and the evolution of nurse midwifery occurred in response to
the need for care by underserved. By the late 1960s, the contributions of nurse midwifery were
accepted and recognized. The profession was inundated with the requests of CNMs and was not
criticized for not having enough CNM trained to meet the needs of women in this country. This
led to proliferation of nurse midwifery educational programmes and development of more nurse
midwifery practices.

Certification
Nurse midwifery education is focused in two areas: (1) providing care to healthy women and
their infants and (2) recognizing significant deviations from the norm that require intervention by
a specialist. In addition to the required classroom work, the programs include a strong clinical
component, often one-on-one with an experienced CNM, designed to develop the skills needed
to translate knowledge into practice. Individual programs may also include research,
administration, or public health classes.

Certified nurse-midwives (CNMs) are registered nurses who have graduated from an accredited
nurse-midwifery education program and have passed a national certification exam administered
by the American College of Nurse Midwives. Certified midwives (CMs) are individuals who
have a background in a health related field other than nursing and graduate from an accredited
midwifery education program. Graduates of accredited programs take the same national
certification exam as CNMs but receive the professional designation of certified midwife.
 Advanced Training
Midwifery is an advanced practice role in nursing. To enter a master's program in nurse-
midwifery, an individual must be licensed as an RN and have a baccalaureate degree.
 Continuing competency assessment
In 1987, the ACNM developed a continuing competency assessment mechanism for it’s
members in clinical practice. It’s purpose was to demonstrate that clinicians continued to
maintain contemporary knowledge and meet a national standard of practice. This five year cycle
requires that practicing midwives either acquire 50 contact hours of continuing education
appropriate for midwifery practice or retake certifying examination.

Scope of Practice

Certified nurse-midwives (CNMs) are providers of primary health care for women and infants.
Primary care by CNMs incorporates all of the essential factors of primary care and case
management that include evaluation, assessment, treatment and referral as required. CNMs are
often the initial contact for the provision of integrated, accessible health care services to women,
and they provide such care on a continuous and comprehensive basis by establishing a plan of
management with the woman for her ongoing health care.
Nurse-midwifery practice as conducted by CNMs is the independent, comprehensive
management of women’s health care in a variety of settings focusing particularly on pregnancy,
childbirth, the postpartum period, care of the infant, and the family planning and gynaecological
needs of women throughout the life cycle.

The certificate to practice nurse-midwifery authorizes the holder, under the supervision of a
licensed physician and surgeon who has current practice or training in obstetrics, to attend cases
of normal childbirth and to provide prenatal, intrapartum and post partum care, including family
planning for the mother and immediate care for the newborn. All birthing complications shall be
referred to the physician immediately. The practice of nurse-midwifery does not include the
assisting of childbirth by any artificial, forcible, or mechanical means, nor the performance of
any version. “Supervision” does not require the physical presence of the supervising physician
when care is rendered by the nursemidwife.

Dispensing
RNs who are certified midwives are allowed to dispense (hand to a patient) medications, except
controlled substances, upon the valid order of a physician in primary, community, and free
clinics. Certified nurse midwives, pursuant to a standardized procedure or protocol in primary,
community, and free clinics are allowed to dispense drugs and devices including schedule lll, lV,
and V controlled substances.

Episiotomies, Repair of Lacerations of the Perineum

CNMs were authorized to perform and repair episiotomies and to repair first degree and second
degree lacerations of the perineum in a licensed acute care hospital and a licensed alternate birth
center if certain conditions were met. These conditions included the supervising physician and
surgeon is credentialed to perform obstetrical care in the facility. The CNM performs and repairs
the episiotomies pursuant to protocols developed and approved by the CNM, supervising
physician, director of the obstetrics department and the interdisciplinary practices committee
where applicable.
Treating STDs
A certified nurse-midwife may dispense, furnish, or otherwise provide prescription antibiotic
drugs to the sexual partner or partners of a patient with a diagnosed sexually transmitted
Chlamydia infection without examination of the patient’s sexual partner or partners.

Advocacy
Advocacy is central to nurse midwifery practice. Client education and support of clients’ rights
and self determination inform every aspect of nurse-midwifery care. With the advancement of
various technologies, the clients’ are not able to make a right decision on the treatment modality
to be followed. The CNMs play a vital role here.
Client education
Client education is another cornerstone of nurse midwifery pratice and is integral to the CNM’s
advocacy role.

Legal Authority for Practice

The Legislature granted the CNM an independent scope of practice. CNMs practice in
collaboration with physicians when appropriate. The degree of collaboration in this team
approach depends upon the medical needs of the individual woman or infant and the practice
setting. For practices and procedures which overlap the practice of nurse-midwifery into
medicine, standardized procedures must be developed and approved by the three entities of the
CNM, physician and practice setting administration.
Citation and Fine
CNMs as RNs are subject to citation and fine for violations of the Nursing Practice Act (NPA).
The Executive Officer, in lieu of filing an accusation against a CNM, may issue a citation which
may contain an administrative fine and/or order of abatement against a CNM for any violation of
law or an adopted regulation which would be grounds for discipline. The violation would not be
of a severity that revocation or restriction of the RN license is necessary. An example of a
violation would be using the title CNM without BRN certification. This fine could range from
$1,000 to $2,500.

Salaries

Earnings vary widely and depend on such factors as place of employment, scope of practice,
education, and experience. According to the Year 2000 Survey of Registered Nurses in Illinois,
59% of the nurse midwives surveyed reported earning between $50,000 and $75,000 per year

Nurse midwifery management process

There are 4 aspects of management :
 Independent management
CNMs provide independent management when they systematically obtain or update a
complete and relevant database for assessment of patient’s health status. This includes the
history, the physical examination results and the laboratory data. On the basis of
interpretation of these findings, the CNMs accurately identifies problems, diagnoses and
implements plan of action.

 Consultation
The CNMs identify problems or complications, they seek advice from another member of
the health care team, often a physician and not always an obstetrician. When they retain
independent management responsibility for patient while seeking advice, it is called
consultation. A consultation may center on an ongoing health problem(eg. Hypothyroidism),
a non- obstetrical time limited problem that arises during pregnancy (eg. Bronchitis or food
poisoning) or an obstetrical complication (eg. Size-date descripamcy). After consultation,
the CNM and the woman discusses the recommendations, if any and modifies the plan of
care.

 Co-management or collaborative care

One outcome of consultation maybe the decision to shift to co-management or collaborative
care. This usually occur if part of women’s care is beyond the scope of the CNM.
  Referral
When CNM identify the need for comprehensive management and care that are outside the
scope of nurse-miwifery practice, they direct the patient to a phycisian or another
professional for the treatment of a particular problem. This management aspect is usually
temporary.

Practice settings
Some of the settings in which CNMs provide labour and delivery care are, patient’s homes,
autonomous birth centres, birth centres within hospitals and traditional labour and delivery
units of the community, regional and tertiary care hospitals.

Professional issues
1. Image
Confusion about the image of midwife stems from different types of midwives that can be found
in the society such as direct-entry midwives, lay midwives and granny midwives. So, the public
image of CNM is unclear. There has been fair amount of professional resistance to CNMs from
the medical community.

2. Credentialing non-nurses (Direct entry midwives)

In 1994, the ACNM made a difficult decision to develop mechanism to accredit midwifery
education programme that do not require nursing credential. This decreased the standard of CNM
practice as a whole.

3. Congruence/ Incongruence of midwifery practice with advance practice nursing

The ACNMs commitments to expand the pool of available midwives and to include the non-
nurse midwives in a diverse midwifery workforce make it difficult for the organization to
advocate masters level preparation for all CNMs. In this sense, midwifery is diverging from the
vision of advance practice nursing.
4. Collegial relationship and autonomy
Barriers to effective working relationship between CNMs and physicians often arise within
organizations.

5. Barriers to practice
a. legislative regulatory and financial barriers- Restrictions to practice can be found in local, state
and federal levels. Inequable reimbursement for service still remains as a problem
b. High workload
c. Malpractice issues- CNMs are facing limited options to obtaining reasonable and
comprehensive professional liability coverage.

CONCLUSION
Even with the resistance of medical community, APNs graduate and work for the betterment of
the clients. It improves the scope of nursing practice to leaps and bounds and with this, advance
practice nurses help to raise the overall image of nursing profession.

BIBLIOGRAPHY

1. Hamric. Ann. B. (2000). Advance practice nursing, an integrative approach. Third

edition. Saunders publications. Missouri.
2. Mundars Julie. (2001). Nurse practitioners’ legal reference. 1st edition.
Springhouse publications. Pennsylvania.
3. Barker. Anne. M. (2008). Advanced practice nursing – Essential knowledge for
the profession. Third edition. Jones and Bartlett publishers. Massachussets.
4. Potter. A. Patricia, Perry Ann Griffine. (2006). Fundamentals of Nursing. Sixth
edition. Mosby publications. Noida.
5. Ellis Rider Janis. (2004). Nursing in today’s world. Nineth edition. Lippincott
Williams and Wilkins Publications. Philadelphia