Abstract
Nursing work has evolved tremendously over the last century, raising ongoing questions about nursing’s professional status. Through various strategies, professionalization in nursing has to some extent been accomplished, although autonomy over nursing practice has been elusive. This is especially so in the contemporary health care system, in which managerial control is emphasized and physician dominance continues. In response to professional constraints in traditional work settings, nursing self-employment is growing. In this study I used focused ethnography to explore the professional experiences of Canadian self-employed nurses and to reconsider nursing knowledge, ethics, and professionalism in this unique context. Despite the barriers they faced, these nurses offered a perspective on nursing professionalism that transcends classic professional traits, showing how the concept of professionalism can be invoked not as a way to “prove” status but as a way to describe a sense of commitment and the contribution to societal well-being.
For much of their history, nurses have been caught between medical dominance and bureaucratic hierarchies, which has challenged their efforts to practice in a manner they themselves define (Liaschenko & Peter, 2004; Rutty, 1998). Nurses have struggled to achieve professional status and demonstrate that they possess the requisite professional traits (Clarke, 2008). Although their attempts to achieve professional status have in several ways succeeded, nurses, especially those working in hospitals, generally continue to work under the legitimating authority of physicians (Clarke). Moreover, in the contemporary delivery of health care there is increasing bureaucratic control and emphasis on cost efficiency, routinization, technology, and physician-based interventions. Throughout its history “one gets a sense that the nature of nurses’ work has always been less than ideal” (McIntyre & McDonald, 2003, p. 295). In response to this complex situation, some nurses have pursued self-employment or private practice as a route to professional satisfaction. These nurses are unique in that they are not organizational employees; thus, they provide a unique perspective for investigating the meanings of nursing professionalism.
A Brief History of Nursing Work
Early nursing work was based on the idea of nursing as a vocation or calling that capitalized on what were seen as inherently feminine characteristics, such as caring for and supporting others (Carr, 2003; Cutcliffe & Wieck, 2008; McPherson, 2003). Nursing is an “occupation that embodies the seemingly universal characteristics of feminine healing, caring, and nurturing” (McPherson, p. 1). Nursing continues to contend with a firmly rooted perception that it is an unskilled, emotional, subservient, and low-value occupation for women (Adams & Nelson, 2009; Porter, 1992), and the sustained subordination of nurses to mainly male physicians and administrators has been attributed by some authors to patriarchy (McPherson).
During the early 1900s, nurses in Canada were mainly untrained women whose work resembled domestic labor (Brannon, 1994; Coburn, 1988). Those training in hospitals were unpaid apprentices, more exploited than educated (Coburn). In the late 1800s and early 20th Century, many nurses worked for private patients (Brannon; McPherson, 2003). By 1930, 60% of nurses worked in private duty (Coburn), though they still functioned under the authority of physicians. Many experienced exhausting work, role ambiguity, jurisdictional conflicts, professional isolation, lack of protection and constructive supervision, expectations of selflessness, and dependence on families as employers (Brannon; McPherson). Nevertheless, these nurses enjoyed a unique level of professional autonomy, task variety, and equality (McPherson). With additional training, some nurses moved into public or occupational health. They enjoyed greater autonomy than their colleagues in private duty and hospital employment, working in areas such as maternal–child health, health education, and social health; they did, however, face disadvantages common to other nurses, such as organizational issues and jurisdictional conflicts with physicians (McPherson).
Socioeconomic change in Canada gradually led nurses back into hospitals, reinforcing nursing’s subordination to bureaucracy and medicine. Since the mid-20th Century, the vast majority of nurses have worked in hospitals or for large employers (Canadian Institute for Health Information [CIHI], 2010; Coburn, 1988). Although in many ways nursing represented an opportunity for women to engage in a skilled occupation, it was precisely this skill that created the conditions for their professional difficulties (McPherson, 2003). As hospital-based care became more technological and specialized, nurses took on some of the physicians’ responsibilities, while having to protect those associated with their own role from lower-skilled workers (McPherson). Through this transformation nurses have experienced lessening control in the labor process and a deskilling of their work (Coburn; Rankin & Campbell, 2006; Shannon & French, 2005)—even more so in the last two decades.
Given emerging market-based ideologies, the publicly funded Canadian health care system has undergone dramatic, efficiency-focused restructuring (Daiski, 2004; Laschinger, Sabiston, Finegan, & Shamian, 2001; Reay & Hinings, 2005; Shannon & French, 2005). Nurses have experienced increased workloads, job uncertainty, disrupted professional relationships, and significant work-related stress, along with moral distress and systemically produced compassion fatigue (Aiken, Clarke, Sloan, & Sochalski, 2001; Austin, 2011; Austin, Goble, Leier, & Byrne, 2009; Austin, Lemermeyer, Goldberg, Bergum, & Johnson, 2005; Daiski; Ingersoll, Fisher, Ross, Soja, & Kidd, 2001; Laschinger et al., 2001; Shannon & French). Changes to health care in Canada and elsewhere have included care standardization, nursing workforce downsizing, increasing management surveillance and control, and a focus on efficiency at the expense of nursing ethics and professional development (Austin; Daiski; Hertting, Nilsson, Theorell, & Larsson, 2004; Ingersoll et al., 2001; Laschinger et al.; Norrish & Rundall, 2001; Rankin & Campbell, 2006; Rudge, 2011; Shannon & French).
Global rates of nursing self-employment are rising, largely because of health care restructuring, the shift toward more community-based care, and nurses’ increasing educational levels (Arcangelo, 1994; Hammond & Gourlay, 1993; Schulmeister, 1999; Wright & Dorsey, 1994). The International Council of Nurses (ICN; 2004) has shown support for the move toward nursing entrepreneurship because of the possibilities it holds for nurses’ independence and expanded roles. Similarly, the nonregulatory Canadian Nurses Association (CNA; 1996) supports the opportunities for nurses inherent in entrepreneurial practice, provided they can exist within a publicly funded health care system. The ICN has noted, however, that the emergence of nursing self-employment is accompanied by unique legal, regulatory, and professional questions.
The ICN (2004) has estimated that about 1% of nurses are self-employed, yet there is almost no published scholarly inquiry to be found on self-employment, and the existing literature on private practice nursing is mainly practical and motivational. However, this literature reveals issues such as the scope of practice, resistance from others, requirements for physician supervision, and traditional ideas within society, health care, and nursing itself that cause independent nursing practice to be misunderstood and undervalued (Arcangelo, 1994; Hammond & Gourlay, 1993; O’Connor, 2003; Porter-O’Grady, 1997; Segal-Isaacson, 2004; Stine, 2001; Wilson, Averis, & Walsh, 2003; Wright & Dorsey, 1994).
Nurses are taught to advocate for their patients and challenge the system, but organizational hierarchies and managerial expectations have increasingly limited their decision-making latitude and interfered with nurse–patient relationships (Rankin & Campbell, 2006; Shannon & French, 2005). Liaschenko and Peter (2004) argued that nurses will likely never achieve autonomy over their practice in the contemporary health care environment. In some ways nurses have been resistant to change, but perhaps more have been complicit in the devaluing and rationalization of their work, and uncritical or unaware of the issues they face, thus helping to perpetuate a business-focused model of care that is at odds with their professional ethics (Austin, 2011; Carter, 2007; Rudge, 2011). Self-employed nurses are a worthwhile group to study because they represent the few who, in their attempts to advance professionally, have dramatically departed from nurses’ traditional organizational circumstances.
Professionalism in Nursing
Some authors have regarded nurses as semiprofessionals, without authority over their own work (Coburn, 1988; Katz, 1969; McPherson, 2003). More recently, nursing has been described as an “insecure profession” that has a confused jurisdiction and operates under bureaucratic control in an area in which the supremacy of another profession is firmly established (Nottingham, 2007). Nursing’s apparently permanent insecurity as a profession (Nottingham) has meant that “for many years and across various countries, nurses have tried to construct persuasive arguments that they are members of a profession and thus worthy of being called ‘professionals’” (Cutcliffe & Wieck, 2008, p. 500). Once emphasizing womanly devotion and subservience to physicians, the focus of nursing gradually shifted to “higher educational standards, greater self-regulation, nursing theory and research [distinct knowledge], and the status of being separate from, but equal to, medicine” (Coburn, p. 441), consistent with sociological thought that specified these as distinct professional traits (Clarke, 2008; Keogh, 1997; Yam, 2004).
Although their pursuit of professional status has in part succeeded, nurses have consistently failed to address the issue of autonomy (Clarke, 2008; Liaschenko & Peter, 2004; Rutty, 1998; Yam, 2004), mainly because of the link between autonomy and knowledge. Nurses can appear to have no distinguishable knowledge base vis-à-vis physicians (Adams & Nelson, 2009; Katz, 1969; Newman, 2002). Early nursing theory was in fact organized around the medical model (Rutty; Yeo, 2004), and nurses have typically been viewed as mere “extensions of the hands of male physicians” (Adams & Nelson, p. 5). However, an alternative view of nursing as a profession of human interaction and nurturing has begun to emerge (Newman, Sime, & Corcoran-Perry, 2004). New nursing theories and models identify a distinct nursing territory, shifting focus from the biomedical model toward caring, holism, and ethical expertise (Fawcett & Swoyer, 2008; Goodrick & Reay, 2010; Maben & Griffiths, 2008; Nelson & Gordon, 2006). Today’s definitions of nursing reflect an ongoing tension between the rationality and objectivity of professional knowledge and the natural, nurturing knowledge of women (Adams & Nelson; Carr, 2003).
Nursing writers have increasingly called for a rethinking of nursing’s professional goals (Cutcliffe & Wieck, 2008; Liaschenko & Peter, 2004; Nelson & Gordon, 2006; Rutty, 1998). Sociologists and nurses have argued against rigid and exclusive trait-based theories of professions (Carter, 1994; Davies, 1996; Evetts, 2003a; Freidson, 1994, 2001). In today’s dynamic health care context, business discourses and managerialism are pervasive, which has limited professional autonomy by constraining, controlling, monitoring, and evaluating professional decision making, thus undermining and dismantling nurses’ professional contributions (Evetts, 2009; Kuhlmann, 2006; Rankin, 2009; Rankin & Campbell, 2006; Rudge, 2011). The literature about nurses’ work continues to focus to some degree on professionalism, but has shifted toward the proletarianization of nursing work through research into working conditions, work rationalization and intensification, and rigid hierarchical control over nursing (McPherson, 2003). However, although apparently a separate paradigm of research, the study of nurses’ work experiences is deeply underpinned by nurses’ longstanding struggle for professional status (Wall, 2010).
Despite the threats to professionalism posed by managerialism, it has been noted that society still needs, wants, and appreciates professionals, and benefits from their expertise and values (Freidson, 2001). Furthermore, Evetts (2003a) has pointed out that the idea of professionalism is increasingly appealing as a way of producing social and occupational change. Sociologists have suggested that those studying professions should now examine how the concept of profession is used by certain occupational groups in everyday work, explore the reasons for the increasing appeal of professionalism, and consider the roles of institutions and the public in shaping conceptions of professions (Dingwall, 2008; Evetts, 2003a, 2003b; Freidson, 1994). In addition, investigating the strategies professional groups employ to enhance their status might offer new insights into the nature of professional work (Abbott, 1988; Freidson, 1994; Hughes, 1971).
In the study of nursing professionalism and work, it is also necessary to emphasize the importance of nonhospital settings of nursing work to highlight the variety of roles that fall within the realm of nursing practice (Elliott, Toman, & Stuart, 2008). Although the study of nursing work has focused to a great extent on hospital-based practice, it is noted that “place needs to be considered as a significant variable . . . in shaping nursing identities and nurses’ work [because it] reveals considerable diversity in the ideas, concepts, and meanings associated with nursing work” (Elliott et al., p. 7). This study of self-employed nurses offers a glimpse into that diversity and the meanings associated with professionalism for this distinct group of practicing nurses.
Study Methods
My approach in this study on self-employed nursing was focused ethnography, an excellent method of examining the cultural context of these nurses’ experiences. Culture consists of the patterns of behavior of a particular group of people and their customs, ideas, beliefs, and knowledge; studying culture reveals what people know, believe, and do (Roper & Shapira, 2000). As with other forms of qualitative research, an ethnographic approach offers a way to explore previously unexamined topics and/or groups from the perspectives of the participants themselves (Morse & Richards, 2002). As a unique form of ethnographic research, focused ethnography is used to “elicit information on a special topic or shared experience” (Morse & Richards, p. 53), and is especially relevant when conducting applied social research in highly fragmented and specialized fields of study (Knoblauch, 2005; Morse & Richards; Roper & Shapira). Participants might not know each other but might still have common behaviors and experiences and share a cultural perspective (Morse & Richards; Roper & Shapira).
The study setting was a western Canadian province. In this province, 241 nurses were registered as private practice (self-employed) nurses during the study period (J. Machtemes, personal communication, November 2, 2007). Although this number is growing, it represents a fraction of the registered nurses (RNs) in the province, 79.1% of whom work in front-line positions in health care organizations, with 65.8% of them in hospitals (CIHI, 2010).
Recruitment was undertaken with the assistance of the provincial association of registered nurses in private practice (hereafter ARNPP). This organization is a nursing special-interest group affiliated with the provincial regulatory association. Nurses approved for independent practice by the regulatory association are encouraged but not required to join the ARNPP. The ARNPP leadership team was extremely enthusiastic about and supportive of this study; a letter outlining the study and asking for volunteer participants was sent by an ARNPP staff member to all of the association members accessible by email. Nurses were sought who had been self-employed for at least 18 months and whose practices had been approved by the regulatory association as independent nursing practices. Once the initial participants responded, additional participants were recruited using snowball sampling, in which those already involved in a study recommend other potential participants (Morse & Richards, 2002).
Twenty self-employed nurses participated (19 women, 1 man). The 20 nursing businesses in this study can be most broadly categorized into clinical and administrative practices. Clinical practices were those pertaining to the direct observation, assessment, and treatment of patients. Administrative practices involved planning for and evaluating the operation of units, programs, and services pertinent to health services delivery. More specifically, the study participants worked in areas such as management and management consulting, occupational health, sexual health, wound care, complementary therapies, foot care, corporate wellness, laser hair removal, and professional practice and quality-of-care complaint investigations. Most of the nurses had graduate education and/or specialty training in their fields.
Nursing registration was not necessarily required for some of the participants to establish their self-employed practices; however, because all of them wanted to be able to identify themselves as nurses and the work they did as nursing, they had undertaken the process of having their practices/businesses recognized as nursing practices. Canadian nurses are regulated by legislatively empowered provincial regulatory associations. Self-employed nurses in this province who wish to be recognized by the regulatory association are required to apply for approval of their practices by completing a lengthy (15-page) and detailed form, in addition to the relatively streamlined annual renewal form submitted by all registered nurses. This approval designates their practices as nursing practices and allows them to count their working hours toward the maintenance of their professional licenses.
Sixteen of the study nurses had practices that were approved by the provincial regulatory association as independent nursing practices, in keeping with the initial recruitment criteria. The intention behind this criterion was to ensure that study participants were working in practices that were externally judged to be nursing practices. As the study progressed, however, it became apparent that there were some valid questions among study participants about the provincial regulatory association’s criteria for evaluating the nursing focus of some independent practices. Thus, 4 other participants whose practices had not been approved were included in the study, because other standards could be applied to determine whether their businesses were nursing practices. For example, although Steve’s occupational health practice had not been approved, occupational health nursing is recognized as a nursing specialty by the Canadian Nurses’ Association.
I collected my data mainly through interviews, which were conducted during 2008. These lasted between 60 and 90 minutes. They were held in locations of each participant’s choosing, including clinics, their homes, my private university office, and coffee shops or restaurants. I audiotaped the interviews and transcribed them verbatim. Participants were asked about their motivations to become self-employed, the supports and barriers to independent practice, others’ perceptions about their practices, regulation and policy relevant to independent practice in nursing, business success, business and professional ethics, the nursing knowledge and skills used in their practices, and the level of autonomy they experienced. I used an interview guide but also let the conversations move naturally, according to what each participant wished to express. This is an accepted interviewing technique in ethnographic research; the interview has some structure but each participant is able to provide detailed, complex answers and tell an uninterrupted story (Morse & Richards, 2002).
Time in the field was limited in this study because of an ethics requirement that I not be present during patient encounters, and because of particular sensitivities for certain participants (e.g., the confidential nature of complaint investigations). Although there is no general rule about the right amount of time to spend in the field (Roper & Shapira, 2000), I attempted to maximize it. I was able to spend a day observing one nurse in her role as a project manager. I also attended six meetings of the ARNPP, including their annual meetings in 2008 and 2010. These meetings gave me a chance to talk to self-employed nurses other than those I interviewed, and to hear more about pertinent issues. I was also able to discuss my preliminary findings directly with private practice nurses and receive assistance with and validation of the interpretations of the interview data. Ultimately, the nurses described similar issues and experiences, confirming data saturation. In qualitative research, data saturation is achieved when the investigator has a sense that there are no new directions to be explored and data collection is complete (Mayan, 2009; Morse & Richards, 2002). Relevant legislation and policy documents were also reviewed to shed light on the requirements and context of private practice.
For the greater part of my analysis, I followed an iterative process of coding, categorizing, and abstracting. Coding involves the identification of persistent words, phrases, and/or concepts within the data (Mayan, 2009). Codes are then sorted and collated to form categories, in which similar codes or excerpts of data are grouped and labeled (Mayan). In ethnography, abstraction involves the creation of linkages among categories, the identification of themes and patterns, and the development of explanations about social and cultural situations in the context of the study (Morse & Richards, 2002). I used NVivo 7 qualitative data analysis software to assist with data management and analysis.
In this study I investigated the perspectives of self-employed nurses in one Canadian province. There are, then, some limitations to the research related to the sample and setting. At the outset of the study, I had planned to include in the data collection interviews with key representatives of the provincial nurses’ regulatory body because of the unique regulatory issues raised by this type of practice. Unfortunately, this opportunity did not materialize. The regulatory association staff were unable to participate, in part because of the contentious and unresolved issues around nursing self-employment, and also because other regulatory issues demanded attention. The perspectives of officials from the regulatory association would be important to obtain in future research on this topic. Future research would also benefit from an examination of the varying practices, philosophies, and issues across Canadian regulatory jurisdictions.
Ethics approval was obtained for this research through the university-based research ethics committee for my discipline. Ethical issues, including the recruitment and data collection processes, informed consent, protection of participants’ privacy, respect for participants’ time, and data storage, were included in my approved proposal. Participant names used herein are pseudonyms. The nurses who participated in this study referred to themselves both as nurses in independent practice and nurses in private practice. Both terms are in use in reference to self-employed nurses, and I use them interchangeably. The term private practice is increasingly favored as a way of recognizing that some employed nurses also function independently in some respects. Self-employment means being one’s own boss, with or without the assistance of employees (Krahn, 1995). Independent contractors such as self-employed nurses are not employees; they bear the economic risk of their employment and control their own work in terms of how they accomplish their role’s expected outcome (Kalleberg, 2000).
Findings
Seeking Autonomy in Nursing Practice
Many of the nurses in this study started private practices because of dissatisfaction with the conditions of traditional nursing employment. Carla described maturing as a person and a nurse, prompting her to explore the “spirit of nursing”:
Everything I believe I am—innovative, professional, problem-solver, empowered, all those things—I could not use in the hospital. Those skills are not needed there. They are valued in different ways but they are not needed in the way that I could uniquely present them.
Carla saw independent practice as a response to becoming “restless with the servitude.” The hospital experience was also frustrating for Denise. In employed nursing, she had always questioned structures and practices, and was perceived as a “problem nurse.” What was missing for her “was probably the creativity—thinking of something and being able to do it.” She found an outlet for her ideas in her private practice.
Other nurses described feeling constrained by their employers, pushing them toward self-employment. Steve had “had enough with dysfunctional organizations,” which Mary Jane described as “limit[ing] your abilities to think outside the box, think for yourself, do something unique, and make a difference.” Evelyn, a wound care specialist, sought a work environment in which she would “be able to do what I wanted to do rather than what an employer wanted me to do.” Inez described her employed working environment as “demeaning” because of the lack of supports and resources, and explained that the work was not “at all challenging or fulfilling.” Doris felt that the quality of her working life had been too dependent on “the attitude of who happened to be the team leader at the time.” Similarly, Gabby decided that she could not “let them—the establishment, the health care system—keep pushing me around.” She chose self-employment so she could have manageable and satisfying responsibilities. Clearly, many of the nurses in the study sought meaning and structure in their work that was not available to them in traditional employment settings.
A Nursing Identity
Almost all of the nurses identified strongly with nursing because it represented trust, knowledge and skill, and personal meaning. When Diana ventured into self-employment, she was certain that she would start a nursing business. She declared her “strong value in registered nursing. I would never want to give up my registration. I’m always, first, and foremost a nurse.” Denise described how nursing was “so important to me. I went in for the right reasons. Bedside nursing wasn’t my niche because it was just too confining, but I never left nursing.” She felt that, in her private practice, she was “the biggest PR [public relations] person for nursing.” Kelly “knew [she] didn’t want to abandon nursing,” despite her strong entrepreneurial drive.
Nursing Knowledge and Its Contribution
These nurses’ professional identities were linked to their knowledge, skill, and ethics. They invoked an inclusive definition of nursing practice and knowledge. Across practice types, they saw nursing as holistic, professional, patient-focused, and prevention-based. Diana explained that even though she was hired for her administrative skills, she brought a “nursing lens” to her work. She pointed out that
it comes back to knowing how to do things because of being a nurse. It’s assessing the problem, diagnosing what the problem is, deciding on some actions that you want to take and evaluating it—the nursing process. It works in project management.
Sophie also identified the distinct nursing perspective that she brought to her administrative work. She explained: “I do know how the system works and I do think I bring a patient-centered approach. I do always try to keep that in my head. Also, I think nurses have the biggest picture for patients.”
Many of these nurses described nursing’s unique, holistic approach. Lindsay felt that her private practice allowed her to be “the best nurse I have ever been in my life” because it is such a “holistic practice that covers everything I’ve learned through my nursing career.” She believed that “nursing is very much about getting people off on their own and being well.” Nancy concurred that private practice nursing rested on “a belief in prevention and holism.” Paula described holism as nurses’ “capacity to see the whole picture and to understand what others are doing in this whole picture.” Like others, she portrayed nurses as “so patient-focused and so family-focused.”
Nurses from diverse practices described the value of nursing in their work. Diana described her contribution as “value-added by bringing nursing knowledge” to a project she was managing. Her perspective had always been appreciated because “you do see things . . . your network is so broad and you have your knowledge base.” Similarly, Sheila talked about her ability to see underlying health problems when advising clients. She felt that “because of my nursing background, I am able to offer them something different.” Carla summed it up by saying, “It’s not the tasks we do. It’s how we inform the experience of health. That’s what we do. We innovate health.”
Several of the nurses talked about the quality that nurses bring to a patient encounter. Two nurses, Gabby and Doris, highlighted the time that nurses spend with patients. Doris observed that although a physician made the same amount of money per patient, “he was seeing five or six in the hour I’m talking to [one].” Gabby concurred, noting that “the doctor comes in and looks at you for three seconds and then is gone,” but a nurse’s work is thorough. Gabby often saw patients after they received a pedicure, which cost more than her services, only to have to spend time addressing foot problems that had not been properly treated. Doris talked about the care, attention, and patient teaching that went into her work so that her clients “feel like they had a pedicure, although it’s from a nursing point of view.” Carla, a leader and advocate among self-employed nurses, pointed out the value of nurse-provided foot care. She said, “We know that they’re not just doing foot care. They’re doing a health assessment, they’re talking to the elderly about their drugs, a person about their diabetes. They’re examining, they’re doing the whole nursing assessment.”
Relational skills were central to these nurses’ experiences. Allison observed, “There’s a huge difference between going to an esthetician for a service and going to a nurse. There’s a certain professionalism and nurturing that is natural to us that an esthetician wouldn’t have.” She remembered one client who had had a bad experience with an esthetician: “He felt like they were just trying to take his money and they didn’t really care for him, but he felt here that he was actually cared for, that he was comfortable.” She believed “that’s just natural to nurses . . . you are the confidante . . . you use a lot of nursing communication skills.” Denise explained that although “I was court-ordered to see most of my clients, and that doesn’t really give you a great start right off the bat,” she was able to see tremendous success in her work with families because “nursing is so respected. . . . It is not threatening. It is always about helping, not taking.” Likewise, Sylvia met many family members who were stressed and worried about a loved one’s care. She observed that “families are immediately comfortable when they know a nurse is investigating the case.” She noted that family members “bring me in to interview their parents and say, ‘This is Sylvia. She’s a nurse.’” To her, this meant that “they’re telling their mom or dad, ‘Here’s a person we can trust.’”
Most of these self-employed nurses left their traditional employment because of organizational constraints that limited their professional contributions and job satisfaction. Although they each sought different types of independent roles, all of them continued to identify strongly with nursing and were certain that their nursing knowledge and ethics formed the foundation of their work.
Perceptions of Nursing Private Practice
Although these nurses were certain about their nursing identity, they encountered resistance and skepticism from members of the public, other professionals, and from within nursing itself. Mary Jane summed up the reactions to private practice nursing when she said, “Nobody likes change. Change is hard. To be the first is hard.” The general public appeared to have difficulty comprehending a role for nurses outside of hospitals. Denise lamented this, noting that “it’s a very funny concept that society has of nursing. It’s perhaps not as empowering as I would like.” She was asked “questions like, ‘How can you be [in business]? You’re a nurse.’” Likewise, Carla was asked questions that reflected “the usual perception of nursing,” such as, “What hospital do you work at?”
Associating nursing with business motives was also problematic, especially for nurses working directly with individual clients. Some services nurses provide in private practice are covered by private insurance plans, but some clients are required to pay out of pocket for care, which is in conflict with long-held Canadian values about publicly funded care. Mary Jane was questioned about her ethics because, in the absence of insurance coverage, she charged her clients directly. Carla commented passionately on this topic:
We are allowed to be accessible as long as we’re serving, but God help you if you try and make money doing it because then you’re greedy and you’re bad. Any nurse that makes good money at giving care is a leech. She’s doing fee-for-service. She’s doing private care. That’s evil. But if you serve and keep your head low and don’t ask for too much, be happy with your shift work, and never quibble, you’re a good nurse.
These nurses strongly believed that their services should be covered by health insurance to ensure accessibility, but they were caught in an in-between space in a system that did not recognize their work as independently insurable. In spite of the issues, however, almost all of these nurses had very busy practices. Regardless of the role or setting, there was a high demand for their services among specific segments of the population.
Other health professionals did not always appreciate private practice nursing. One psychologist approached Paula on the subject of access to nurses with mental health expertise and said, “I think you’re just taking over.” One nurse’s foot care practice was described by a doctor as “a pretty nice racket.” She believed he was comparing her with a podiatrist who saw many patients per hour, which was different from the time-consuming work she did. Nancy saw “a fear of spiritual healing being out in the open” because “there is no time for compassion in Western medicine.” She found that “some physicians are on board but there is still a lot of resistance and they feel threatened.” Steve found that managers in industry were often unfamiliar with his area of practice and could have “a bad perception of what they think the nurse’s role should be”:
The further we move away from acute care, the more grey it becomes. In acute care, it’s very structured, very formal. This is the job of a nurse, this is the function of a nurse. When you move away from that and there are other professions involved, those boundaries are less clear.
Denise, however, was able to articulate a cooperative vision for working with other health professionals despite areas of overlap. She expressed assurance that “we’re not here to take your jobs away. We’re so complementary to other disciplines. It’s just so important that we find a piece of the puzzle that we fit into.”
The nurses also evaluated themselves and each other vis-à-vis conventional nursing practice. Two nurses in administrative practices were reluctant to join the ARNPP because they anticipated meeting “other nurses [who] had more traditional practices” (Wendy), and “nurses who were doing ‘real’ nursing” in clinical practices (Sheila). Notably, most nurses mentioned “foot care nurses,” citing them as the prototypical nurses in private practice because they provided direct patient care. Nancy perceived a general comfort with traditional nursing, saying, “There seems to be a feeling always that you have to keep up your traditional nursing skills,” although she believed that “nurses need to rethink this.” Despite their inclusive definitions of nursing as applied to their own work, several of the nurses in the study still held underlying conservative understandings of nursing, unknowingly perpetuating constraints against nursing self-employment.
Regulation of Nursing Self-Employment
The most stressful issues for these private practice nurses pertained to regulation. General misunderstandings about independent nursing practice became significant threats when it came to professional licensure. Denise shared a common experience when she said that she had “cried more in my career as a private nurse about [regulation] and being afraid of being kicked out [of nursing] and being afraid of not doing something.” In this province, independent practice nurses must apply to the regulatory association for recognition of their nursing practices, allowing them to accrue hours toward their annual registration. Carla acknowledged that “they’re [the regulatory association] trying to make an assessment. They feel they have the safety of the public at heart,” but she believed “they lack understanding . . . they try to cover so much [on the application form], asking inane questions, questions that aren’t even related to the practice or comparisons that don’t even fit.” For Paula, the application process did not allow her to “convey . . . how I viewed myself as a nurse and what my nursing practice was about.”
Several of the nurses reported waiting for many stressful months to learn the outcome of their respective application; some became “paranoid” about the meaning of the delays. A few nurses had been unable to count their initial self-employed hours toward their registration renewal because their practices had not yet been approved. Because of regulatory delays, Paula was unable to count hundreds of practice hours, even though her practice was eventually approved. Mary Jane’s license lapsed as she waited, derailing her plans for a health education business/practice.
Several nurses questioned the level of regulatory scrutiny over independent practice. Kelly said, “Why do I have to justify myself when no other nurse does? I know a lot of nurses, and their practice isn’t necessarily scrutinized like this is.” As Evelyn expressed, “There is far more rigor in my independent practice. Nobody’s watching me in my [concurrent] paid employment.” Ironically, Lindsay noted that “probably my standards are even higher [than an employed nurse] because I am the one responsible for them.” Carla and Mary Jane had each gone through all of the provincial nursing practice standards/indicators to assess their own practices, a process they believed most hospital-employed nurses could not undertake. As Carla pointed out, “Professionalism is everything for the private practice nurse.” She saw private practice nurses as highly invested in the success of their practices, not just financially but in securing the public trust and demonstrating competence. Despite this, these nurses felt unduly policed.
Although peer review is a privilege associated with professional self-regulation, several self-employed nurses regarded it as a surveillance tool that did not fit well with their practices. Denise often spoke to nursing groups; she would “speak to five or six hundred nurses a year,” hearing their issues, ideas, and responses, but the regulatory association saw this as insufficient feedback about the quality of her practice. Doris had a letter of endorsement from the nursing staff in one care facility but was asked by the regulatory association “to physically have somebody in the office watch me do it.” Similarly, Evelyn was asked to engage someone to observe her work directly; this was difficult to arrange because of a lack of available nurses with her skill set. Wendy was also expected to find a peer to observe and evaluate her leadership, although she “get[s] peer review every day from the nurses. . . . If they don’t like what’s going on, they phone me.”
Many of the nurses were frustrated by the regulatory association’s narrow operational definition of nursing. Nurses working in clinical roles had less difficulty gaining approval, but there were instances in which even they had trouble. Steve had been unable to secure approval for his practice because the regulatory association had deemed “that occupational health nursing was not in the scope of practice of a nurse.” Ironically, however, occupational health nursing is a recognized specialty of the Canadian Nurses’ Association. Steve explained:
I can’t call myself a nurse because my association doesn’t understand what I do. I remember taking those courses in nursing school: What is a nurse? What is a profession? Here’s a prime opportunity to show what a nurse can do, and yet we don’t get support from our own organization.
Denise worked hard to teach “unique ways of getting staff to buy into wellness and buy into health,” but was asked to demonstrate “how I incorporated nursing into what I did.” She felt that the regulatory association was just looking for competence with standard technical skills. She was also asked why she was not associated with a physician from whom she could take direction.
Conflict with the regulatory association was seen as unsupportive and paternalistic. Some nurses wondered why the regulatory association would want to make it difficult for excellent nurses to be nurses. Denise believed that a different approach would have been more effective, and that the regulatory association “could protect the public so much more if they would empower and nurture their people.”
Potential and Possibilities Through Independent Practice
Despite their struggles, the nurses spoke enthusiastically about the potential for professional satisfaction and contribution through nursing self-employment. They spoke of satisfiers such as professional latitude, autonomy, professional learning and growth, and being seen as an expert. Paula explained that she “was in a unique position to make a difference,” a perspective echoed by Sheila, who believed that “the work that I’m doing makes a difference to people in the world.” Similarly, Evelyn described the satisfaction she derived from “seeing the results with the clients. I see how appreciative the clients are that I’m able to improve their quality of life and improve their health status.” Paula saw her private practice as the pinnacle of her career:
The self-employed practice that I’m engaged in now is a career culmination. All of the threads of my nursing background are present and active. . . . It’s increased my satisfaction with my own career and allowed me again to refocus on the beauty and meaning of it. I get to taste it again in a renewed way. It’s like [my career] is at the ten-thousand-foot level instead of five.
Beyond job satisfaction, many of the nurses had a new vision for nursing that might be accomplished through independent practice. Lindsay believed that nurses are positioned “to think about how we’re failing from the traditional point of view [and] how we could add to it.” Nancy saw on the horizon an “important shift from the traditional perspective,” utilizing holistic healing and viewing patients as partners in their own care. Steve saw independent practice as a way to “expand our role and educate people about registered nurses.” Others viewed private practice nurses as the leaders and innovators in professional nursing, the “people who take the initiative to pave the way that changes the future” (Mary Jane).
Discussion
The participating nurses’ nontraditional responses to long-standing professional issues in nursing present an opportunity to think about nursing professionalism in a new light. They saw the potential for independent practice to promote new ideas about health and health care and create new opportunities for nursing. Many of them encountered barriers, but they also experienced significant personal and professional satisfaction and a sense of contribution. These nurses were able to break away from the need to demonstrate their professional status according to classic professional traits. The key issue for them was not whether they were indeed professionals, but rather finding a practice setting that would allow them to exercise their professional capabilities to the full extent, beyond the constraints of managerialism and medical dominance.
Nursing self-employment affords the opportunity to consider the nature of knowledge used in nursing practice that is truly independent. It was once suggested that nursing abandon its “inauthentic aspirations and positions . . . [so that] the dysfunctional consequences of attempts to pass [as professionals] will tend to disappear,” leaving nurses with the ability to ‘be themselves’” (Etzioni, 1969, p. vii). Since then, nursing scholars have questioned the professionalization agenda in nursing, given its lack of success and its increasing irrelevance in contemporary health care (Liaschenko & Peter, 2004; McPherson, 2003; Rutty, 1998). Notably, these self-employed nurses demonstrated that acquiescence might not be the only response to the elusive professional status of nursing. They saw nursing knowledge as a useful means to “inform . . . [and] innovate health” (Carla) rather than prove professional standing. They also demonstrated that “being themselves” might mean more than just accepting their organizational fate or the proletarianization of their work.
The traditional focus on professional traits, coupled with a focus on hospital-based practice, has led to narrow understandings about nursing’s potential and, ultimately, discouragement about nursing’s professional status. This study supports Elliott and colleagues’ (2008) assertion that attention to nonhospital settings might enhance scholarship in this area. Although traditional trait theories of professions have been called into question, Freidson (1994, 2001) suggested that, because of the complex, esoteric, and valuable work that professionals do, expertise, specialized knowledge, autonomy, and credentialism continue to be important to establish an identifiable and reliable occupational group, ensure competence and public protection, and allow for discretionary professional judgment in the care of individuals. In describing their professional experiences, these nurses did indeed draw from these aspects of professionalism. They also conveyed the value they placed on ethical relationships in their work, showed how their work was important for the well-being of individuals or of society at large (Freidson, 1994), and demonstrated a professional “commitment to place service to society and often to the individual ahead of, or at least equal to, personal gain” (Garrett, Baillie, & Garrett, 2010, p. 19).
Defining the unique professional knowledge of nursing practice has been difficult. Diers (2004, p. 158) acknowledged the diversity of nursing but claimed that the “essence of the practice, and thus the knowing, is caring.” Similarly, a holistic orientation has been attributed to nursing that emphasizes an integrated, enlightened, innovative approach to care (Cowling, 2007). These ideals might not be realized for nurses constrained by organizational and professional hierarchies because they are limited in their ability to exercise the moral and relational foundation of their work (Austin, 2011; Pauly, Varcoe, Storch, & Newton, 2009). For the nurses in this study, however, these were essential aspects of their roles. They often described how caring and holistic orientations formed the basis for their work, in terms of nurturing, trust, communication, patient empowerment, and the quality of their services. This was as true for nurses working as management consultants as it was for those providing direct care. Notably, these nurses saw caring and holism actualized because of their autonomy to practice in ways they most identified with nursing values and knowledge.
Dingwall and Allen (2001) claimed, conversely, that it is unrealistic to continue to focus on caring and emotion work in (hospital) nursing. Moreover, Nelson and Gordon (2006) argued that an emphasis on nurses’ virtue and emotional work obscures their concrete knowledge and reinforces gender stereotypes. They went on to point out that nurses have considerable scientific and medical knowledge, highly developed communication skills (knowledge-based rather than “natural”), and extraordinary logistical, multitasking, and management skills that enable them to deal with people in challenging circumstances, understand the complexity of the system, and ensure the safety of those in their care.
The nurses in this study described how they dealt with the physical, psychological, and social needs of individuals, developed and implemented illness-prevention and health-promotion programs, managed administrative projects, and investigated complaints about the safety and quality of care, relying on the nursing process to structure their work. They also demonstrated that it is possible to blend nursing’s moral orientation to practice and some of the more concrete knowledge and activities that nursing involves. Although the full meaning and nature of nursing has been elusive in traditional work settings, these nurses were able to draw on a more balanced, comprehensive definition of professional nursing knowledge and practice. This is significant in that it moves away from typically dualistic thinking about nursing professionalism that sees nursing as either knowledge work or caring work, and that has contributed to commonly accepted but inadequate descriptions of nursing practice (Adams & Nelson, 2009).
Traditional definitions of professionalism generally include ethical considerations. However, what stood out among the self-employed nurses in this study was the relational nature of their professional ethics. Nurses in contemporary health care organizations work in “morally uninhabitable” work environments that are “dominated by the values of others” (Peter, Macfarlane, & O’Brien-Pallas, 2004, p. 361), including the traditional, codified, impersonal, and abstract bioethical approaches. Although the nurses still respected and adhered to nursing’s formal code of ethics, their vision of nursing ethics emphasized the everyday issues of health care practice as they occur in relationships with others (Bergum & Dossetor, 2005; Liaschenko & Peter, 2004). They spoke at length about ethical concepts such as caring, nurturing, communication, collaboration, patient/client empowerment, respect, and trust, and the ways these played out in their daily work. Their professional ethics were based on an ideology of “serving through relationship,” which focused on connecting and making a contribution to the community (Fenwick, 2002, p. 713) rather than on proving professional status. Their emphasis on the moral dimensions of practice and their ability to enact these demonstrate a culture of nursing practice that is difficult to achieve in today’s organizationally based nursing practice environments (Austin, 2011).
In this province, recent legislation has blurred the boundaries of professional jurisdictions to make them more flexible. This has the potential to erode the scope of nursing practice and/or offer nurses new avenues for professionalization. Sociologists have recognized that professional groups move in and out of jurisdictions as they are newly created, vacated, or challenged (Abbott, 1988). Self-employed nurses have taken the new legislation as an opportunity to redefine nursing and expand its influence. In doing so, they are attempting to expand their mandate, defining for themselves on behalf of others what they believe to be their occupational domain (Hughes, 1971). These nurses have moved away from hospitals into workplace wellness, health care planning, alternative and complementary therapies, esthetics, consulting, counseling, health education, and facilities management, using their nursing knowledge in jurisdictions that might be understood as belonging to others.
These nurses’ attempts to expand their jurisdictions and mandates are in keeping not only with sociological theorizing but also contemporary nursing thought. Many nursing scholars “embrace the full range of nursing knowledge forms as long as [they] have relevance to the profession or practice of nursing” (Algase, 2006, p. 267). The Canadian Nurses’ Association (2006, 2008) recognizes that nursing practice occurs in four domains: clinical practice, research, administration, and education. These perspectives permit a broad and inclusive interpretation of the scope of nursing practice on which the nurses in this study have capitalized. It is this inclusive perspective that has allowed nurses in such diverse independent practices to identify with nursing and claim to be using nursing knowledge, despite the ways their roles might push the conventional boundaries of nursing.
The nurses invoked the idea of professionalism as a value system rather than a strategy for status advancement (Dingwall, 2008; Evetts, 2003b). In contrast to the erosion of the professional scope of practice that organizationally based nurses are experiencing (Adams & Nelson, 2009; Shannon & French, 2005), these nurses found through self-employment a means for flexible and interesting work that enabled them to express their own ideas and values about care. They had control over their professional goals and activities, allowing them to experience a strong sense of personal satisfaction and contribution to others over time. Through their innovative professional practices they were able to reclaim and retain their unique professional identity (Freidson, 1994), and look forward to a career in which they could be “excited by the prospect of practicing to their full scope and tailoring their services to meet specific client needs” (CNA, 1996, p. 1). Separately and collectively, these nurses had a strong vision of how independent nursing practice could fill gaps in existing health services through an expanded range of services and a broader perspective on nursing’s contribution to health—one that is preventive, empowering, holistic, and innovative.
These private practice nurses have, through jurisdictional challenges, also pushed at the limits of their professional licensure. Regulatory issues were, for them, perhaps the most significant stressor. Although they understood the responsibility of the regulatory association to protect the public and ensure competence, they felt that regulatory scrutiny restricted the potential of independent nursing practice. Unresolved issues in private practice nursing include the lack of public funding, specific and relevant standards, and monitoring and accountability mechanisms. These have impacted the comfort level of regulatory associations with regard to independent nursing practice (CNA, 1996; ICN, 2004; Wright & Dorsey, 1994). There is work to be completed to create the plan and infrastructure to support private practice nursing and integrate it into the health care system (CNA, 1996; ICN). This will assist in maximizing nurses’ potential professional contributions in independent practice.
It might be that the regulatory difficulties these nurses experienced arose because they were “such an anomaly to the profession” (Porter-O’Grady, 1997, p. 23). Because “affiliation and identification represent the usual path for being invited to the forums and to the tables of policy making and national leadership” (Porter-O’Grady, p. 23), these nurses might be less able to participate in reasonable discussions about the legitimacy of their practices and the supports required to advance and sustain them. An overly ambitious mandate can lead to broken dreams, chronic dissatisfaction, and poor morale, whereas an overly restrictive license can deny a profession the benefits of creativity and innovation (Dingwall & Allen, 2001). Private practice nurses and their regulatory associations must strive to achieve a balance between public interests and safety, and innovative nursing practice. Such efforts are just beginning in this study province.
Significantly, nurses’ professional issues have been ongoing and consistently resistant to change (Shannon & French, 2005); therefore the exponentially rising number of self-employed nurses signals an important and intriguing professional trend (CNA, 1996; ICN, 2004). These are still early days for independent nursing practice. There are controversies to resolve and questions to answer, yet these nurses found a way to exercise their vision of professional nursing in unprecedented ways. They demonstrated how it is possible to incorporate divergent ideas about nursing knowledge and professional ethics and realize them across a range of autonomous practice settings. In doing so, they offered a glimpse into what nursing might be if nurses were empowered to be self-directed, and they highlighted important reasons to continue examining independent nursing practice for its potential to address questions about nursing professionalism that have for so long been elusive.
Footnotes
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author received no financial support for the research, authorship, and/or publication of this article.