The document discusses issues related to independent nursing practice, specifically for nurse practitioners and midwives. It defines nursing and the roles of nurse practitioners who can manage medical conditions, order tests, treatments, and medications. It also defines independent nurse practitioners and midwives. Key issues for independent practice include scope of services, conflict of interest, endorsement, advertising, fees, informed consent, documentation, confidentiality, and liability protection. Areas of independent nursing practice are also outlined, along with standards and challenges for independent midwifery practice in India.

1. INDEPENDENT PRACTICE
ISSUES IN NURSING
Ms ARIFA T N
FIRST YEAR M.Sc NURSING, MIMS CON

2. INTRODUCTION
 DEFINITION OF NURSING
 According to Virginia Anderson
Assisting the individual, sick or well, in the
performance of those activities contributing to health
or its recovery (or to a peaceful death) that he would
perform unaided if he had the necessary strength,
will, or knowledge. And to do this in such a way as to
help him gain independence as soon as possible

3. INTRODUCTION
Nurse practitioner(NP’s) manage acute and
chronic medical conditions, both physical and
mental, through history and physical examination
and ordering of diagnostic tests and medical
treatments. NP’s are qualified to diagnose medical
problems, order treatments, perform advanced
procedures, prescribes medicines and make
referrals for wide range of acute and chronic medical
conditions within their scope of practice.

4. INDEPENDENT NURSE PRACTITIONERS
 Self employed nurses
 Still bound by all nursing legislations and standards
 Face some unique challenges

5. DEFINITION
 Nurse practitioners (NPs)
Nurse practitioners (NPs) are registered nurses who
have graduate level nursing preparation as a nurse
practitioner at the master’s or doctoral level and
perform comprehensive assessments and promote
health and the prevention of illness and injury.

6.  An INP is defined as, “A registered nurse who
provides professionals nursing services as a
proprietor of a business, through direct patient care,
education, research, administration or consultation.”

7. DEFINITION
 Nurse practitioners (NPs)
A nurse practitioner (NP) is defined as , “ an
advanced practice registered nurse (APRN) who has
completed graduate level education ( either a master
of nursing or doctor of nursing practice degree).

8. KEY PRACTICES COMPONENTS TO
CONSIDER THE SCOPE OF SERVICES
 A nurse needs to clearly identify that he/she is
providing nursing services, the extent of those
nursing services and under what conditions he/she
will refer clients to other health care professionals
 Must maintain the high standards of nursing and
uphold the public trust that has been bestowed on
the nursing profession

9. KEY ISSUES TO CONSIDER-
PROFESSIONAL ISSUES
 Conflict of interest
 Endorsement
 Advertising
 Fees
 Informed consent
 Documentation
 Confidentiality
 Other issues
 Liability protection
 Networking
 Business or legal council

10. Conflict of interest
 Primary obligation is providing professional care to
his/her clients
 In a position of trust and cannot use their position to
influence their clients for financial gain of non
financial benefit

11. Conflict of interest
 Avoid selling products or services to clients they are
treating
 Avoid conflict of interest situations in their practice,
particularly when it comes to the endorsement and
advertising of products

12. Endorsement
 Endorsing or promoting a product or services is
closely linked to conflict of interest
 Endorsement occures when a nurse uses her
credentials to lend credibility to a commercial product
line or service

13. Endorsement
 The endorsement of a product or service without
providing information about other options could
mislead the public and compromise trust
 For example, a nurse in independent practice who
provides foot care services should not sell any foot
care products for her clients.

14. Advertising
 There are limitations on how a
nurse can advertise his or her
services
 Advertising may take various
forms, such as business cards
listing 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, fee, address and
phone number

15. Practice guideline independent practice fees
 The college does not
determine or approve
specific service fees.
According to Nursing Act
1991 and the accompanying
regulations, the following
activities related to fees are
considered professional
misconduct.
a. Submitting an account or
change for services that the
member knows is false or
misleading
b. Failing to fulfill the terms of an
agreement for professional
services

16. Practice guideline independent practice fees
c. Changing a fee that is
excessive in relation to the
service for which is charged
d. 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 qualification
and experience and who
provide comparable
services

17. Informed consent
 Nurse 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

18. Informed consent
 Treatment is defined as anything that is performed for
a therapeutic, preventive, palliative, diagnostic,
cosmetic or other health related purposes, and
includes a course or plan of treatment

19. Documentation
 An integral part of 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 the health care team
and how to continuity of care is maintained
 They also demonstrate the nurses accountability and
answer questions about the type of care provided

20. Confidentiality
 Nurse in independent
practice are requires to
maintain the
confidentiality of the 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

21. Other issues
 Regulated professionals may incorporate their
independent practice under legislation
 Business or legal council
 Liability of protection
 Networking:

22. Other issues
 Regulated professionals may incorporate their
independent practice under legislation
 Business or legal council: nurses may want to
seek legal advise before starting an independent
nursing practice
 Liability of protection: the college recommends
that nurses in independent practice purchase liability
protection to enable public redress if any problems
occures
 Networking: entrepreneurial support groups for self
employed nurses offer assistance with peer
feedback, idea and issue sharing, planning for
vacation and sickness etc.

23. AREAS OF INDEPENDENT NURSING
PRACTICE
CONSULTANCY GERIATRIC
NURSING
MEDICAL SURGICAL
NURSING PRACTICE
PAEDIATRIC
NURSING
PSYCHIATRIC
NURSING

24. AREAS OF INDEPENDENT NURSING
PRACTICE
SCHOOL HEALTH
NURSING
ADULT NURSE
PRACTITIONER
FAMILY NURSE
PRACTITIONER
ACUTE CARE
NURSE
PRACTITIONER
MIDWIFERY AND
WOMEN’S HEALTH
NURSING

25. RESPONSIBILITY OF A INDEPENDENT
NURSE PRACTIONER
 Universal precautions
 Unacceptable practices
 Verifying recipient eligibility
 Private duty nursing requirements
 Emergency and back-up procedures
 Written statement of recipient rights
 Contracts with recipient and/or family
 Required information for medical record
 Terminating service to a recipient

26. INDEPENDENT NURSE
MIDWIFERY PRACTITIONER

27. INTRODUCTION
 Activities of health care providers who are experts in
women health care including prenatal care to the
expectant mothers, attending at birth and providing
post partum care to mother and infant
 Practitioners of midwifery are known as midwives.

28.  Independent midwifery practice enables registered
nurse midwives to utilize their knowledge skills,
judgment and authority in the provision of midwifery
practice package and primary women’s health
services while maintaining accountability for the
management of patient care in accordance with
midwifery standards laid down by the midwifery or
nursing council of their country

29.  Independent should not interpreted to mean alone,
as there are clinical situations when any prudent
practitioner would seek the assistance of other
qualified.

30. MIDWIFERY PRACTICE PACKAGE FOR
INDEPENDENT PRACTICE
• Access to a midwife 24 hours a day , 7 days a week
• Two midwives available alternatively and provide
women centered antenatal, intrapartum and
postnatal midwifery care.
• Antenatal care in privacy
• Continuity of care through out labour
• Post natal care up to 6 weeks
• Knowledgeable breast feeding support

31. STANDARDS FOR MIDWIFERY PRACTICE
 Midwifery practice as conducted by midwife is the
independent management of women's health care
focusing particularly on pregnancy, child birth, the
postpartum period care of newborn, family planning
and gynecological needs of women

32.  Midwives provide consultation management,
collaborative management or referral as indicated
according to standards of midwifery practice
 In India as such standards of midwifery practice act
are not developed to do independent midwifery
practices which are one of the essential
requirements.
 American college of nursing midwives has defined
eight standards of practice

33. STANDARD 1
 Midwifery care is provided by qualified
practitioners
 Midwifery should be registered
 Shows evidence of continuing competency as
required by certification agency by council
 It is in compliance with the legal requirements of
the jurisdiction where the midwifery practice
occurs

34. STANDARD II
 Midwifery care occurs in a safe environment
within the context of the family, community and a
system of health care
 Demonstrate a safe mechanism for obtaining
medical consultation , collaboration and referral
 Uses community services as needed

35. STANDARD II
 Demonstrate knowledge of the medical,
psychological , economical , cultural, and family
factors that affect care
 Demonstrates appropriate techniques for
emergency management including
arrangements for emergency transportation
 Promotes involvement of support persons in the
practice settings

36. STANDARD III
 The midwives practices in accordance with the
philosophy and code of ethics of the professional
body provides clients with a description of the scope
of midwifery services and information regarding the
client’s rights and responsibilities
 Provides clients with information regarding services
when care required is not within the midwives' scope
of practice

37. STANDARD III
 Provides client with information regarding health
care decisions and the state of science regarding
these choices to allow for informed decision making
 Midwifery care supports individual rights and self-
determination within boundaries of safety

38. STANDARD IV
 Midwifery care is comprised of knowledge, skills,
and judgments that foster the delivery of safe,
satisfying, and culturally competent care.
 The midwife collects and assesses client care
data, develops and implement individualized plan
of management and evaluates outcome of care

39. STANDARD IV
 Demonstrates the clinical skills and judgments
described in the basic midwifery practice.
 Practices in accordance with standards
 Practices in accordance with service or practice
guidelines that meet the requirements of the
particular institution or practice settings

40. STANDARD V
 Midwifery care is based upon knowledge, skills, and
judgments which are reflected in written practice
guidelines and are used to guide the scope of
midwifery care and services provided to clients.

41. STANDARD V
 Midwifes describes the parameters of services for
independent and collaborative midwifery
management and transfer of care when needed
 Establish practice guidelines for each specialty area
which may include, but is not care of the child
bearing family and newborn care

42. STANDARD VI
 Midwifery care is documented in a format that is
accessible and competent
 The midwives uses records that facilitate
communications and institutions

43. STANDARD VI
 Provides prompt and complete documentation of
evaluation, course of management and outcome of
care.
 Promotes documentation system that provides for
confidentiality and transmissibility of health records
 Maintain confidentiality in verbal and written
communications

44. STANDARD VII
 Provides for systemic collection of practice data as a
part of a programme of quality, management
 Seeks consultation to review problems, including
peer review of care
 Acts to resolve problems identified

45. STANDARD VIII
 Midwifery practice may be expanded beyond the set
competencies to incorporate new procedures that
improve care for women and their families
 The midwife identifies the need for new procedure
taking into consideration consumer demand,
standards for safe practice and availability of other
qualified personnel

46. STANDARD VIII
 Ensures that there are no institutional state or
council statures, regulations or laws that would
constrain the midwife from incorporation of
procedure into practice
 Reports the incorporation of this procedure to the
authority. In respect to provide standardized practice
independently, the nurse midwife has to meet
required education, experience, advanced skills and
competency

47. CHALLENGES FOR INDIAN MIDWIVES
 PRACTICE CHALLENGES
 CHALLENGES FOR LAW REGULATION
 EDUCATIONAL CHALLENGE
 CHALLENGES FOR RESEARCH ACTIVITIES
 CHALLENGES FOR POLICY MAKERS

48. PRACTICE CHALLENGES
 Midwives should be recognized as independent
practitioners with the rights and responsibilities
regarding scope of practice. Authority and
accountability that all Independent by share.
 Health organization should use to allow quality and
standard based midwifery care.
 Midwife should ensure case consultation,
collaboration and referral provided to a woman
without interruption and for overall benefits

49. CHALLENGES FOR LAW REGULATION
 State regulators should enact laws which are based
on entry to practice standards on successful
completion of midwifery educational programme.
 Health care system should develop privileging and
credentializing mechanisms for midwives that are
consistent with professional standards, recognize
established process that permits midwives to build
upon competencies within their statutory scope of
practice.

50. EDUCATIONAL CHALLENGE
 Direct entry midwife programme to create a new
category of professional midwife.
 The midwifery profession should identify, develop
and implement mechanism to recruit midwives who
reflect Indian population with their competencies.
 It is needed to develop categories of midwives as
per their expertise in their midwifery

51. CHALLENGES FOR RESEARCH
ACTIVITIES
 It is required to continually grow and evolve in order
to provide evidence based midwifery practice which
will help to practice independently.
 Analysis of midwifery practice in view of consumers
or women who receive care.

52. CHALLENGES FOR POLICY MAKERS
 Some of the most pressing issue regarding
midwifery go beyond the current scope of regulatory
bodies, professional associations, educators and
practitioners.
 Policy makers are to be convinced for the
importance of independent practice.
 Research efforts have found the midwifery makes a
positive contribution to the health of the women and
babies.

53. Conclusion