SCHOOL OF NURSING SCIENCE AND RESEARCH

(SHARDA UNIVERSITY)
ASSIGNMENT
ON
INDEPENDENT NURSE PRACTICE
SUBMITTED ON: 20
th
March 2020
SUBMITTED TO:- SUBMITTED BY:-
Mrs. Christa Mathew Ms. Samjhana Neupane
Assistant Professor Msc. Nursing 1
st
year
Advanced Nursing Department SNSR
SCHOOL OF NURSING SCIENCE AND RESEARCH
(SHARDA UNIVERSITY)

ASSIGNMENT
ON
INDEPENDENT NURSE –MIDWIFERY PRACTITIONER

SUBMITTED ON: 26th APRIL 2020

SUBMITTED TO:- SUBMITTED BY:-
Mrs. Christa Mathew Ms. Samjhana Neupane
Assistant Professor Msc. Nursing 1st year
Advanced Nursing Department SNSR

Introduction:
 Self employed nurses
 Still bound by all nursing legislation and standards
 Face some unique challenges
Nurse practitioner (NP’s) manage acute and chronic medical conditions, both physical and
mental, through history and physical examination and ordering of dignostic 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.
In addition to building upon and expanding their nursing knowledge and skills,the nurse
practitioner also learns medicine and uses medical diagnoses and medical treatments in their
practice.
Definition of Nurse Practitioner:
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).
Nurse practitioner (NP) are registered nurses who have graduate level nursing preparations asa
nurse practitioners at the masters or doctoral level and perform comprehensive assessments and
promote health and the prevention of illness and injury”.
Independent nurse practitioner:
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.”
The international council of nurses defines INP:
“ A registered nurse who has acquired the expert knowledge base, complex decision making
skills and clinical competencies for expanded practice”.
American academy of nurse practitioners:
An independent nurse practitioner is referred as advanced practice nurse has a master’s degree in
nursing in the specialized area of her/his interest and licensed to practice in his/her state”.
Philosophy of INP:
 The core philosophy of INP is to provide individuals care to patient of all ages. Its care
focuses on patient’s conditions as well as the effects of illness on the lives of the patients
their family.
 INPs make prevention , wellness and patient education priorities. This means fewer
prescriptions and less expensive treatment.
 Informing patients of their healthcare and encouraging them to participate in decisions
central to the care.
 In addition to care, INPs conduct research and are often active in patient advocacy
activities.
Historical development of INP:
Nurse practitioners have provided a healthy partnership with their patients for more than 40
years. INP role originate as one strategy to increase access to primary care. The following are
brief historical background of INP:
 The nurse practitioner’s role had its inception in the mid 1960’s in response to a shortage
of physicians. The first NP program was developed as a master’s degree curriculum at the
University of Colorado’s School of Nursing in 1965, founded by Loretta C Ford, a
nursing faculty member and Dr Henry K Silver , a pediatrician. Programs were developed
across the country to provide additional education for experienced nurses to enable them
to provide primary health care services to large underserved populations. The first
programs were in pediatrics and they soon spread to many other health care specialities.
 During 1970-1971, federal legislation recommended certificate program for nurses to
deliver primary health care.
 Gradually certificate program shifted to master’s degree.
 In response to healthcare reform in 1990’s, 3 INP programs were developed to meet the
demand of primary care services.
 By 1994, 248 programs centers were developed for INP in US.
 In 1995, 49000 nurses were employed as INPs.
 American academy of nurse practitioner in 1993 developed standard and guidelines for
practice of INPs which are still followed.
 Today 200 universities and colleges are offering INP program all over the world.
 70000 nurses are working as INP in US.
Development of Independent nurse practitioner (Independent Nurse Midwifery
Practitioner) development in India
 The Indian Nursing Council (INC), the parent body of the nursing councils in the
country, has rolled out an initiative, which is in the early implementation stage, and has
been forwarded for approval to the Union Health ministry.
 Independent nurse practitioners trained in midwifery has been introduced to bring down
the high Maternal Mortality Rate (MMR) and Infant Mortality Rate (IMR) in rural
areas. The National Population policy 2000 includes reduction of maternal and infant
mortality as one of the socio-demographic goals to be achieved by 2010. The single most
important way to reduce maternal death in India would be to ensure that a skilled health
professional is present at every birth. Skilled care during childbirth is important because
millions of women and newborns develop serious and hard to predict complications
during or immediately after delivery. Skilled health professions such as doctors or nurses
who have midwifery skills can recognize these complications and either treat them or
refer women to health centers or hospitals immediately if more skilled care is needed.
 So, in order to ease the impact of the shortage of gynaecologists in community health
centres, INC performed a pilot study for the ‘Independent Nurse Practitioner Project’ in
West Bengal at SSKM Hospital’s female medical and surgical wards. The project
provides an 18 months training in midwifery, besides an additional training in emergency
obstetric care to candidates who have completed their BSc in nursing and have two to
three years of clinical experience in ob-gyn wards to take care of ANMS in rural sector.
These nurses are called independent nurse practitioners as they are trained to prescribe
medicines following approved protocols and take decisions independently in absence of
gynaecologists.
 2 of the 4 trainees have been assigned to a CHC to manage obstetric cases.
 The results of the pilot study has been submitted to health ministry and the government of
India is currently examining the proposal to extend this project all over India. INC is
finalising a curriculum with senior obstetrics and gynaecologists for the training of
independent nurse practitioner module.
 Explains T Dileep Kumar, president, INC, “In rural areas, though a community health
centre should be manned by physician, surgeon, paediatrician and gynaecologist, the
community health centre is usually found facing a shortage of gynaecologists. It’s in such
a scenario, that the role of independent nurse practitioner gains importance, here,
Auxiliary midwives are trained. Independent nurse practitioners should be regarded as a
part of solution for improving quality, access and cost of care and continuing education.”
BASIC requirements of Independent nurse midwifery practitioner
Becoming Independent nurse midwifery practitioner is one of the important challenges as it
needs specialized qualification. The basic requirements are mentioned below:
 Basic nursing education
 Registered nurse
  Advance Nursing Certification (Master Degree in Obstetics and gynaecology nursing)
 Collaboration with any hospital/agencies for referral and reimbursement.
Areas of practice
Independent nurse midwifery practitioners work in a variety of settings, including:
 Community Clinics and Health Centres
 Nurse managed centres
 private practices (either by themselves or together with a physician),
 hospitals,
 nursing homes,
 birthing centers.

 Women’s Health Clinics

 Home health care agencies/Home Nursing

 Schools or colleges based health clinics

 They often provide care to underserved populations in rural areas or inner-city settings.
Functions of Independent Nurse Practitioner:
 Midwifery nurse practitioner is a registered professional nurse, 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.

 She is prepared to practice in an expanded role to provide primary care to women, to

well-woman related to reproductive health, conduct annual gynecological exams, provide
education regarding family planning, and provide menopausal care.

 She provides care in a variety of settings including, but not limited to homes, hospitals,
institutions, community agencies, public and private clinics, and private practice. She acts
independently and/or in collaboration with other health care professionals to deliver
health care services.

 She conducts comprehensive health assessments aimed at health promotion and disease
prevention. She is 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.
  Midwifery practitioners are specialists in low-risk pregnancy, childbirth, and postpartum.
They generally strive to help women to have a healthy pregnancy and natural birth
experience. They are trained to recognize and deal with deviations from the normal.

 Midwifery nurse practitioners 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. Their focus of care is
on health surveillance (promotion and maintenance of wellness), but it also provides for
management of complications in order to maintain continuity.

 Midwifery practitioners refer women to general practitioners or obstetricians when a

pregnant woman requires care beyond the their’ area of expertise. They are trained to
handle certain more difficult deliveries, including breech births, twin births and births
where the baby is in a posterior position, using non-invasive techniques.

 Nurse-midwives work together with OB/GYN doctors. They either consult with or refer
to other health care providers in cases that are outside of their experience (for example,
high-risk pregnancies and pregnant women who also have a chronic disease).

 Many studies over the past 20 – 30 years have shown that nurse-midwives can manage
most perinatal (including prenatal, delivery, and postpartum) care, and most of the family
planning and gynecological needs of women of all ages. Nurse-midwifery practitioners
have improved primary health care services for women in rural and inner-city areas.

Advantages of Nurse Practitioner:

 NP’s are uniquely focused on “caring” as opposed “curing”.

 NP’s combine nursing education and experience with through education in medical care
for their speciality care

 They takethe “whole person” into account, not just the immediate ailment.

 NP’s provide patient centered care.

 They are specifically trained to educate and support individuals and families, helping
them change behaviours and make informed, individualschoices about their health and
their healthcare.

 NP’s provide high quality, cost effective care.

 One study compare the cost of care for two primary care problems and found thatthe cost
care given by NP’s was20% less thanthe cost of care given by physicians.
SCENARIO OF MIDWIFERY IN INDIA

 Prof. Uma Handa (ex Consultant Midwife, UNICEF) has a BS and an MSc in Nursing
with specialization in obstetrics and gynecology. She has worked in the field of nursing
since 1974, in nursing educational institutions in both the conventional and distance
system, as well as in national and international health agencies.

 Countries in which she has worked include Sri Lanka, UK, Bangladesh and South Africa
(University of Namibia-UNAM). She has received many special awards throughout her
career. Uma’s present goal is to promote independent midwifery practice in India to
encourage mothers to go through natural childbirth and so that unnecessary medical and
surgical interventions can be prevented.

 Organizations she is member of: Nursing Research Society of India (Founder), Trained
Nurses Association of India (TNAI), White Ribbon Alliance India (WRAI), Society of
Midwives, and Executive Committee member Birth India.

Issues in independent nurse practice

Nursing has been thought to be a part of the medical ‘team’ where all professionals provide input
to build the best care of the patient but now times have changed nurses have developed
themselves as independent professionals with a unique body of knowledge.

Some of the issues and challenges of INP are mentioned below:

1) Curriculum for independent nurse practitioner development:

Early nurse practitioner training involved non degree, certificate programs of one year or less.
Today the nursing community strongly supports master’s degree preparation for entry-level
practice. Although the level of education is higher, the focus has remained the same: Nurse
practitioner programs emphasize primary care, preventive medicine and patient education.

However, physicians offer a different service to patients. With five years of medical education
and three years of residency training, their depth of understanding of complex medical problems
cannot be equaled by lesser-trained professionals.”

2) Prescriptive authority:

Nurse practitioners have the authority to prescribe and can write prescriptions (including ones for
controlled substances) without any physician involvement. However, some believe that there
should be collaborative prescribing agreement between nurse practitioners and physicians.

3) Public view of nursing:

Many articles in nursing as early as 1928, speak to the concerns about nurses. “Nice girls, don’t
do nursing!”. “If you have a strong back and weak mind, be a nurse” The public’s images of
nurses has not essentially changed since nursing’s inception. In public opinion, nurses are
identified as a means for decreasing the cost of health care. She is considered as “a highly trained
professional who is providing an alternative to the expensive primary care physician”. They
wonder that can she do anything that a primary care physician can do.” They are reluctant to
recognize nurse practitioners as primary care providers.
4) Areas of practice:
“Non physician providers have historically thrived in settings where physicians were
unavailable — places they were unable or unwilling to go,” “It remains to be seen if independent
nurse practitioners will be economically viable in areas of physician oversupply.”
5) Quality of care:

Many studies show that patients have a high or very high level of satisfaction with NP Services.
Regarding measurement of diagnosis, treatment, and patient outcomes, several studies indicate
that the quality of care provided by NPs is equal to that of physicians.

6) Cost effective care:

Nurse practitioners provide a cost effective care. One study compared the costs of care for two
primary care problems and found that the cost of care given by NPs was 20% less than the cost
of care given by physicians. At the same time, some argue that, without ready access to
supervising physicians, nurse practitioners are likely to order more tests and consultations and be
quicker to admit patients to the hospital, thereby driving up health care costs.

7) Insufficient evidence-based practice and nursing research

There is a need of promotion of evidence-based practice and nursing research so that with a
sound knowledge base, the nurses will be able to function more independently. Establishment of
policies on the use of evidence in practice is required. Nurses with a Master’s degree should be
encouraged to provide evidence, read nursing research and use evidence to improve or change
nursing practices. An academic atmosphere should be created in the workplace. An information
system and library should be provided. Multidisciplinary research should be encouraged. At the
hospital, there should be a person who is responsible for nursing research activity including fund
seeking for research and building of research network.

Nurse educators should develop a short-course training on evidence-base and research or to

supervise research activity. Resources such as journals and books can be shared. Joint research
between nurse educators and clinical staff should be encouraged to strengthen the capacity of
both groups and improve education and practice.

The INC can be a part of nursing research development. The INC should set nursing research
priorities in collaboration with nursing and non-nursing organizations to provide research funds
and promote nursing activities for policy formulation. Establishment of a nursing research
information system is encouraged to monitor research work, areas of research and researchers.
Dissemination of nursing research and models for best practices should be established.
 8) Need for establishment of a continuing nursing education system:

Continuing education is an informal study or activity to gain knowledge and learn about new
technology. Lifelong education is essential for self-development, knowledge-building and
learning. Continuing education stimulates nurses to keep up with new knowledge and
technology, to increase their skills and competency, and to be able to contribute to the health care
team.

The existing continuing nursing education programmes should be strengthened or new units
established. The appointment of responsible persons for continuing education activity is needed.
Continuing education programmes should get approval from the INC so that nurses can develop
increased competency to work independently.

9) Need to establish a quality assurance system for the nursing service

A quality assurance system comprises vision, mission, objectives, strategic and operational
plans, nursing service activity, nursing manpower management, roles and responsibilities,
nursing standards, nursing indicators, nursing research, nursing administration and management,
resource allocation and financial support.

The objective of this system will be to ensure quality care and nursing outcomes as expected by
clients (less suffering, shorter duration of hospital stay, and reduction of health care costs,
infection, complications and mortality), and according to professional standards. It also indicates
the commitment of the care provider towards providing the best care to consumers. Successful
development and implementation of the system depends on the commitment of nursing leaders,
hospital administrators, mutual goal-setting, participation of all personnel in the process,
continuous quality improvement and good communication.

The role of the INC in regulating nursing practice should be strengthened by amending the
Nursing Act to include maintaining of registration of qualified nurses, renewal of licence, and
setting up a nursing service and nursing education accrediting system. If possible, a hospital QA
system should have nursing as an integral part and involves nurses in a surveyor team.Thus, this
will help ensure the quality of services provided by independent practitioners

10) Lack of involvement of nurses in health and nursing policy formulation and
planning

There is insufficient involvement of nurses in health.

REFERENCES:

Brar,ncandrawat.hc2015.Textebookofadvancednursingpracce.Jaypee
brothersmedicalpublisherltd
 Brar,nc and rawat.hc 2015. Textebook of advanced nursing practice. Jaypee brothers
medical publisher ltd. Page no: 975-983
 Essays,UK. (November 2018). Independent Practice Issues And Independent Midwifery
Nursing Essay. Retrieved from https://www.ukessays.com/essays/nursing/independent-
practice-issues-and-independent-midwifery-nursing-essay.php
 Shebeer.P.Basheer, S.Yaseen Khan, Aconsise Textbook of Advanced Nursing Practice ,
Emmess Medical Publishers. Edition 2012 Page no:- 694-699
 https://www.slideshare.net/Rv_252/independent-practice-issues-and-independent-nurse-
midwife
SCHOOL OF NURSING SCIENCE AND RESEARCH
(SHARDA UNIVERSITY)

ASSIGNMENT
ON
 INDEPENDENT NURSE PRACTICE & ISSUSES

SUBMITTED ON: 20th march 2020

SUBMITTED TO:- SUBMITTED BY:-

Mrs. Christa Mathew Ms. Samjhana Neupane
Assistant Professor Msc. Nursing 1st year
Advanced Nursing Department SNSR