INDEPENDENT PRACTICE ISSUES-INDEPENDENT NURSE-MIDWIFERY PRACTITIONER

INTRODUCTION
The founder of modern nursing has highly quoted that nursing is the care which puts the person in the
best possible condition for nature to either restore or preserve health or to prevent or cure injury.
Changes in the healthcare and nursing profession have provided nurse with more opportunities to apply
their expertise independently. Nurses who are self-employed are referred to as independently practicing.
Although they are still bound by all nursing legislation and standards, nurses in independent practice face
some unique challenges.

TERMINOLOGIES
Midwifery: Midwifery term is used to describe the activities of health care including prenatal care to
expectant mothers, attending at birth and providing post-partum care to mother and infant.
Midwives: Practitioners of midwifery are known as midwives.

DEFINITION OF INDEPENDENT NURSE PRACTITIONER

 “An independent Nurse Practitioner (INP) is a registered nurse who has completed specific advanced
nursing education (generally a master’s degree) and training in the diagnosis and management of
common as well as complex medical conditions to provide a broad range of health care services.”
- Wikipedia Definition

 “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 her/his state.”
- American Academy of Nurse Practitioners

 “A registered nurse who has acquired the expert knowledge base, complex decision-making skills and
clinical competencies for expanded practice.”
- The International Council of Nurses

PHILOSOPHY OF INP
 The core philosophy of INP is to provide individuals care to patients of all ages. Its care focuses on
patient’s conditions as well as the effects of illness on the lives of the patients and their families.
 INPs make prevention, wellness and patient education priorities. This means fewer prescriptions and
less expensive treatment.
 Informing patients of their health care 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.

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HISTORICAL DEVELOPMENT OF INP
Nurse practitioners have provided a healthy partnership with their patients for more than 40 years. INP role
originated 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- 1960s 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 in1965, 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 nurses to enable
them to provide primary health care services to large underserved populations.
 During 1970-1971, federal legislation recommended certificate program for nurses to deliver primary
healthcare.
 Gradually certificate program shifted to master’s degree
 In response to healthcare reform in 1990s, 3 INPs programs were developed to meet the demand of
primary care services.
 By 1994, 248 programs centers were developed for INP in US.
 In 1995, 49,000 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.
 70,000 nurses are working as INP in US.
Development of Independent Nurse Practitioner (Independent Nurse Midwifery Practitioner) and its
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 introduces 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.
 In order to ease the impact of the shortage of gynecologists in community health centers, 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.
 Two of the four 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 finalizing a curriculum
with senior obstetrics and gynecologists for the training of independent nurse practitioner module.
 Explains T Dileep Kumar, president, INC, “In rural areas, though a community health center should be
manned by physician, surgeon, pediatrician and gynecologist, the community health centre is usually
found facing a shortage of gynecologists. It is 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.”

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KEY PRACTICES COMPONENTS TO CONSIDER THE SCOPE OF SERVICE
A nurse needs to clearly identify that he or she is providing nursing services, the extent of those nursing
services and under what conditions he or she will refer clients to other health care professionals. Nurses in
independent practice must maintain the high standards of nursing and uphold the public trust that has been
bestowed on the nursing profession.
 Conflict of interest:
 Nurses are in a position of trust and cannot use their position to influence their clients for
financial benefit
 Nurses should avoid selling products or services to clients they are treating
 The nurses in independent practice avoid conflict of interest situations in their practice,
particularly when it comes to the endorsement and advertising of products.
 Endorsement:
 Endorsing or promoting a product or services is closely linked to conflict of interest
 Endorsement occurs when a nurse uses her credentials to lend credibility to a commercial
product line or service.
 Advertising:
 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 description of services and nursing credentials, practice
experience, fees, address and phone number.
 Informed consent:
 Nurses in independent practice are expected to obtain informed consent before performing any
treatment
 For consent to be valid, it must relate directly to the treatment.
 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 to the
health care team and how continuity of care is maintained
 Confidentiality:
 Nurses in independent practice are required to maintain the confidentiality of the client
information and cannot communicate the information and cannot communicate the
information to another person unless the client or client’s representative gives consent or it is
required by law
 Other issues and resources incorporation:
 Regulated professionals may incorporate their independent practice under legislation.

 Business or legal counsel:

 Nurses may want to seek legal advice before starting an independent nursing practice.
 Liability protection:
 The college recommends that nurses in independent practice purchase liability protection to
enable public redress if any problem occurs.

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

INDEPENDENT NURSE MIDWIFERY PRACTITIONER

Midwifery term is used to describe the activities of health care including prenatal care to expectant
mothers, attending at birth and providing post-partum care to mother and infant. Practitioners of midwifery
are known as midwives. The role of a midwife whether she practices in hospitals, health centers, or domiciliary
conditions has been recognized as one of the most rewarded job. Her function carries great responsibilities
and demands, specific knowledge and skills. They play a central role in health care delivery-promotion,
prevention, treatment and rehabilitation, in area of great health needs especially in remote areas. The
midwife may practice in any setting including the home, the community, hospitals, or in any other maternity
services.

DEFINITION OF THE MIDWIFE

According to ICM membership (International Confederation of Midwives) and joint study group of
maternity care and WHO, the term midwife is defined as, “A midwife is a person who, having been regularly
admitted to a midwifery educational program duly recognized in the country in which it is located has
successfully completed the prescribed course of studies in midwifery and acquired the requisite qualification
to be registered and or legally licensed to practice midwifery”.

DEFINITION OF INDEPENDENT MIDWIVES

Independent midwives are fully qualified practitioners who, in order to fulfill the midwife’s role to its
greatest potential, choose to work as self-employed professionals – although they support its aims and ideals.

AREAS OF PRACTICE
Independent nurse midwifery practitioners work in a variety of settings, including:

 Community Clinics and Health Centre

 Nurse managed centre
 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.

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ISSUES IN INDEPENDENT NURSE PRACTICE
Nursing has progressed from an occupation to a fully licensed profession, with members that provide a
broad range of services independently, and in a variety of professional relationships with other providers. This
evolution has changed how nurses are educated, clinically prepared, and how they perceive their role.

But, there are certain issues in independent practice:

 Curriculum for independent nurse practitioner development:
 Early nurse practitioner training involved no degree, certificate programs of one year or less.
 Although the level of education is higher, the focus has remained the same: Nurse practitioner
programs emphasize primary care, preventive medicine and patient education.

 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.
 Public view of nursing:
 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.
 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.”
 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.
 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.
 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.
 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.

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  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.
 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.
 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.
 Continuing education programs should get approval from the INC so that nurses can develop
increased competency to work independently.

STANDARDS REQUIRED FOR THE PRACTICE OF MIDWIFERY:

Midwifery as conducted by midwife is the independent management of women’s health care, focusing
particularly on pregnancy, childbirth, the post-partum period care of new born, family planning and
gynecological needs of women. Midwives provide consultation, management or referral as indicated
according to standards of midwifery practice.
In India as such standards of midwifery practice act are not developed to the independent midwifery
practices which are one of the essential requirements. American college of nursing midwives has defined eight
standards of practice.
Standard-I
Midwifery care is provided by qualified practitioners
 Midwifery should be registered
 Shows evidence of continuing competency as required by certification agency or council.
 It is in compliance with the legal requirements of the jurisdiction where the midwifery practice occurs
Standard II
 Midwifery care occurs in a safe environment within the context of the family, community and a system
of health care.
 Demonstrates a safe mechanism for obtaining medical consultation, consultation or referral
 Uses community services as needed
 Demonstrates appropriate techniques for emergency management including arrangements for
emergency transportation
 Promotes involvement of support persons in the practice settings

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Standard III
 The midwives practices in accordance practice with the philosophy and the code of ethics of the
professional body provides clients with a description of the scope of the midwifery services and
information regarding the client’s rights and responsibilities.
 Provides clients with information regarding services when requested or when care is required is not
within the midwife’s scope of practice
 Provides clients with information regarding health care decision making and the state of science
regarding is not within the midwife’s scope of practice
 Provides client with information regarding health care decisions and the state of science regarding
these choices to allow for informed decision making.
Standard IV
Midwifery care is comprised of knowledge, skills and judgment that foster the delivery of safe satisfying and
cultural competent care.
 The midwife collect and assesses client care data, develops and implement individualized plan of
management and evaluates outcome of care.
 Demonstrates the clinical skills and judgments described in the basic midwifery practice
 Practices in accordance with standards
 Practice in accordance with service or practice guidelines that meet the requirements of the particular
institutions or practice settings
Standard V
Midwifery care is based upon knowledge, skill and judgment which are reflected in written practice guidelines.
 Midwife 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 new born care. Includes the following information in each specialty area:
 Client selection criteria
 Parameters and methods of assessing health status
 Parameters for risk assessment
 Parameters for consultation, collaboration and referral
 Approve interventions including treatment, medications and or devices
Standard VI
Midwifery care is documented in a format that is accessible and competent
 The midwife uses records that facilitate communication and institutions
 Provide prompt 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
Standard VII
Midwifery care is evaluated according to an established programme for quality management that includes a
plan to identify and resolve problems.

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  The midwifery participates in programme of quality management for the evaluation of practice within
the setting in which it occurs
 Provides for a 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.
Standard VIII
Midwifery practice may be extended beyond the set of competencies to incorporate new procedures that
improve care for women and their fames.
 The midwife identifies need for new procedure taking into consideration consumer demand, standards
for safe practice and availability of qualified personnel
 Ensures that there are no institutional, state or council statures, regulations or laws that would
constrain the midwife from incorporation of the 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, experienced, advanced
skills and competency.
ROLE OF AN INDEPENDENT NURSE MIDWIFE PRACTITIONER
Her role includes care of the mothers during pregnancy, birth and in the days immediately afterwards before
client come under the care of your local health visitor. She must maintain the high standards of nursing an
uphold the public trust that has been bestowed on the nursing profession.
 Caregiver: Midwives provide high quality antenatal and postnatal care maximize the women’s health
during and after pregnancy, detect problems early and manage or refer for any complication.
 Coordinator: Midwives coordinate care for all women. Coordinator ensures holistic, voluntary and
social services for pregnant women when appropriate so that every women’s birth experience
regardless of risk factor.
 Leader: The role of a leader is to plan, provide and review a women’s care, with her input and
agreement, from the initial assessment through to the postnatal period
 Communicator: As a communicator, the midwives understand the effectiveness of communication. It
helps to develop a trust relationship with pregnant women and family members. The midwives have to
communicate effectively with pregnant women and family members as well as others so that they can
share their all problems.
 Manager: The manager is a great role for the midwife. Midwives manage all the circumstances where
appropriate and can recognize and refer women to obstetricians and other specialists at the time when
necessary.
 Educator: As an educator, midwives provide high quality, culturally sensitive health education to
promote healthy, helpful family life and positive parenting
 Counselor: Midwives provide information and counsel pregnant women on prenatal self-care
including nutrition, hygiene, breastfeeding and danger signs in pregnancy and childbirth.
 Family planner: They also counsel people as a family planner. They provide all information about all
kinds of family planning methods and help couples to take decisions.
 Advisor: Midwives advise on the development of the birth plan and promote the concept of birth
preparedness. They also advise on a complicated situation so that it will help them to take decisions.

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 Record keeper: Record keeping is an integral part of midwifery practice. It helps to make the
continuity of care easier and to enable identify problems in an early stage.
 Supervisor: Supervising and assisting mothers during the antenatal period, monitoring the condition
of the fetus and using their knowledge to identify early signs of complications.

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CONCLUSION:
There are many legal issues confronting practicing nursing today but nurses should view the law, not with
apprehension, but as a helpful partner in defining nursing practice. Nurses who are aware of legal rights and
obligations are better prepared to take of patients. Nurses are responsible for knowing the laws that apply to
their areas of nursing practice.
The strong voice of powerful midwives, working close to government and civil society committed to
improving maternal and newborn health status have realized the goal of achieving independent midwifery
practice.

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 BIBLIOGRAPHY
1. Brar NK. Textbook of Advanced Nursing Practice. 1st Edition. New Delhi: Jaypee Brothers Medical
Publishers (P) Ltd; 2015. Page no. 975-977
2. Baheer SP, Khan SY. A Concise Textbook of Midwives. 2 nd Edition. Bangalore: EMMESS Medical
Publishers; 2017. Page no. 657-659
3. Fraser MD, Cooper Am. Myles Textbook for Midwives. 15 th Edition. China: Churchill Livingstone Elsevier
Limited; 2009. Page no. 7-8
4. Rana S. Independent practice issues, independent nurse midwifery practitioner. Slideshare.net. May
31, 2019 (cited on 07/01/2022). https://www.slideshare.net/sakshirana18/independent practice
issues-11286849
5. Mahapure S. Independent practice in Nursing. Slideshare.net. Nov 15, 2011 (cited on 07/01/2022).
https://www.slideshare.net/smahapure/independent practice issues in nursing-90648788
6. https://nursinganswers.net/essays/independent-practice-issues-and-independent-midwifery-nursing-
essay.php

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