 INDEPENDENT PRACTICE ISSUES AND INDEPENDENT MIDWIFERY

NURSING
 INTRODUCTION

The founder of modern nursing has rightly 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.

Nursing has its own entity and ethics which makes it a profession. In response to the rising health needs, the
need for independent nursing is the demand of the hour. This concept is readily formulated and implemented
in developed countries. This has helped in meeting the consumers’ demand for health benefits.

During the twentieth century, the nursing profession has undergone immense change. 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. Starting with turn-of-the-
century debates concerning the appropriateness of professional nursing practice, registered nurses began
assessing not only their licensure status, but their roles related to other professionals.

In the early years of the nursing profession, it was generally believed that nurses served and cared for their
patients by assisting physicians. However, the perception of nursing often varied dramatically from its
practiceThe role of the public health nurse, as it developed earlier in this century, was often independent, with
nurses working with families of patients with tuberculosis or other highly contagious diseases and providing
a broad range of interventions, both health- and socially-focused.

 Definition of independent nurse practitioner

Wikipedia Definition, “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.”

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 her/his state.”

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.”

 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.

Standards required for practice of midwifery

Midwifery care is provided by qualified practitioner, who is registered

Midwifery care occurs in a safe environment with in context of family, community and system of health care.

Midwifery care supports individual rights and self determination with in boundaries of safety.

Midwifery care comprises of knowledge, skills and judgment that foster the delivery of safe, satisfying and
culturally competent care.

Midwifery care based up to knowledge, skills and judgment which are reflected in written practice guidelines.

Midwifery care is documented in format that assessable and component.

Midwifery care is evaluated acc. to an established prog. For quality management that include a plan to identify
and resolves problem.

Midwifery practices may be extended beyond the set competences to incorporate new procedures, that
improves care for women and their family.

 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 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
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 specialties.

During 1970-1971 Federal Legislation recommended Certificate Programme for nurses to deliver primary
health care.

Gradually certificate programme shifted to master’s degree

In response to health care reform in 1990s 3 INPs programmes were developed to meet the demand of primary
care services.

By 1994, 248 programme centres were developed for INP in US.

In 1995, 49000 nurses were employed as INPs.

A2merican 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 programme all over the world.

70,000 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 skilledhealth
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
1. Independent nurse midwifery practitioners work in a variety of settings, including:
2. Community Clinics and Health Centres
3. Nurse managed centres
4. private practices (either by themselves or together with a physician),
5. hospitals,
6. nursing homes,
7. birthing centers.
8. Women’s Health Clinics
9. Home health care agencies/Home Nursing
10. Schools or colleges based health clinics
They often provide care to underserved populations in rural areas or inner-city settings.

 What Independent nurse midwifery practitioner can do?

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.

 SCENARIO OF MIDWIFERY IN USA

 INDEPENDENT MIDWIFERY PRACTICE
It is the position of the American College of Nurse-Midwives (ACNM) that midwifery practice is the
independent management of women’s health care, focusing particularly on common primary care issues,
family planning and gynecologic needs of women, pregnancy, childbirth, the postpartum period and care of
the newborn. The practice occurs within a health care system that provides for consultation, collaborative
management or referral as indicated by the health status of the client.
Independent midwifery enables certified nurse-midwives (CNMs) and certified midwives (CMs) to utilize
knowledge, skills, judgment, and authority in the provision of primary women’s health services while
maintaining accountability for the management of patient care in accordance with ACNM Standards for the
Practice of Midwifery.

Independent practice is not defined by the place of employment, the employee-employer relationship,
requirements for physician co-signature, or the method of reimbursement for services. Nor should independent
be interpreted to mean alone, as there are clinical situations when any prudent practitioner would seek the
assistance of another qualified practitioner. Collaboration is the process whereby health care professionals
jointly manage care. The goal of collaboration is to share authority while providing quality care within each
individual’s professional scope of practice. Successful collaboration is a way of thinking and relating that
requires knowledge, open communication, mutual respect, a commitment to providing quality

care, trust and the ability to share responsibility.

 SCENARIO OF MIDWIFERY IN UNITED KINGDOM

Independent Midwives UK represent the majority of independent midwives in the UK. The organisation is
committed to improving maternity provision for all women in the UK and is working with other support,
service and professional groups, including the Government, to achieve that objective. Independent Midwives
UK also provides professional advice and mutual support for independent midwives.

The former Independent Midwives Assosiation has recently become Independent Midwives UK, an Industrial
and Provident Society. The new organisation is a Social Enterprise and with Government support, Independent
Midwives UK is working towards making Independent Midwifery available to all women who are entitled to
NHS maternity care.

 Independent Midwife

Independent Midwives are fully qualified midwives who have chosen to work outside the NHS in a self
employed capacity. Independent midwives fully support the principals of the NHS and are currently working
to ensure that all women can access ‘gold standard’ of care in the future ( LINK). The role of the midwife
encompasses the care of women and babies during pregnancy, birth and the early weeks of motherhood.

 Qualification and regulation of midwives

Midwifery is the most securely regulated profession in the UK. All practising midwives must adhere to the
Midwives’ Rules which are enshrined in the 1902 Midwives Act of Parliament and subsequent amendments.
All independent midwives have undertaken full midwifery training and are subject to annual supervisory visits
and equipment checks. In line with the requirements of our regulatory body, the Nursing and Midwifery
Council, we are required to ensure that our clinical practice is up to date and that our actions are within our
sphere of competence.

 Role in emergency conditions

There are very few genuine emergencies during childbirth; this is why research has shown that for most
women homebirth is at least as safe if not safer than hospital birth. As the experts in childbirth, midwives are
trained to recognise any early warning signs that things may not be progressing normally and to take
appropriate action. If the unexpected should happen, all midwives are trained in emergency resuscitation of
both mothers and babies Independent Midwives carry all the necessary emergency drugs and equipment and
these are checked on a yearly basis by a supervisor of midwives.

 Emergency equipments
Independent Midwives carry all the necessary emergency equipment to ensure that if a baby is born needing
resuscitation, this can be performed. For example: oxygen, suction, bag and mask. All midwives are trained
in emergency resuscitation. Independent Midwives also carry emergency drugs in case a woman is bleeding
heavily. They update ourselves on a yearly basis in emergency neonatal resuscitation and many of us have
attended emergency skills workshops tailored for independent midwives attending homebirths.

It is a requirement that our equipment is checked on a yearly basis by a supervisor of midwives. As

Independent Midwives, often working alone and mainly facilitating homebirth, we are very conscious that we
need to be completely up to date with all the necessary skills should an emergency occur.

 Charges for services

As Independent Midwives are all self-employed they are all able to choose what they charge. Independent
Midwives have to cover all their own costs such as training, equipment and travel. Rates may vary in different
areas of the UK; currently a complete package of care will cost you between £2000 and £4500 (approx). Most
Iindependent Midwives will want to receive payment in full by the time you are 36 weeks pregnant but if you
have genuine difficulties in paying please discuss it with your Independent Midwife as most can offer flexible
payment plans.

 Credentials to become a midwife

Becoming an independent midwife can seem a daunting challenge but many midwives have taken the leap
and few regret doing so. Once a midwife has completed an approved programme of education and is registered
with the Nursing and Midwifery Council, (NMC) she/he may practice where ever she/he chooses to in
accordance with NMC rules. In the UK that could be in the NHS, the private sector, with an agency or as an
independent self employed midwife. If a midwife chooses to be self employed she is regulated by the NMC
midwives rules and standards, and must adhere to the same statutory obligations as an employed midwife.

 SCENARIO OF MIDWIFERY IN AUSTRALIA

 Midwives in Private Practice (MIPP)
For centuries midwives have worked among their communities providing care to women. Historically
midwives have held a philosophy of care based on the belief that pregnancy is, basically, a healthy process
and a normal part of life, growth and development. It is this belief that guides the way in which midwives in
private practice work. Midwives choosing to work privately, rather than being employed by hospitals and
other institutions, do so because it allows them to be flexible about the care they provide. That is, the care
offered will be in partnership, directed primarily by the wishes of the women and their families.

The private practitioner midwife is able to provide continuity of care to the families who have chosen to use
her services. During the pregnancy, the woman and her family develop a friendly supportive relationship with
their midwife (in some cases eg homebirth, the care is shared by two midwives). On the day the baby is born
the midwife remains with the woman throughout the entire labour. There are no shift changes that require the
midwife to leave. During the first week of the baby’s life the same midwife visits each day until the baby has
settled into a feeding pattern and the parents feel confident in caring for their new baby.

Some midwives in private practice choose to work in specific areas. For example, some may offer postnatal
care, or advice with difficult breastfeeding problems (Lactation Consultants) or Maternal and Child Health
(M&CHN). In addition, some midwives are skilled and have qualifications in complementary areas such as
acupuncture, counselling, naturopathy, chiropractic, massage or homeopathy.

 The range of services provided:

 Pre-pregnancy advice
 Advice about birth options
 Childbirth education classes
  Sibling preparation classes
 Continuous midwifery care during pregnancy
 Preparation for and attendance at births in an appropriate environment of the parents’ choice
 Postnatal care following birth at home, birth centre or hospital
 Separate postnatal care for women who want private midwifery care for this period only or who are
discharged home early from hospital
 Lactation consultancy
 Acupuncture and Chiropractic

Referral to and advice about other health professionals such as medical and natural health practitioners, eg
obstetricians, paediatricians, GPs, chiropractors, osteopaths, naturopaths, homeopaths

Some midwives have a special interest and expertise in supporting women in special areas such as vaginal
birth after caesarean section (VBAC), breech births, water births and postnatal depression.

 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.

The nurses could not document that they hold a patient’s medications based on ‘nursing judgment’. Such an
instance might be when a patient had hypotension from pain medication and thus the morning anti-
hypertensive is held. Instead, they need an order from a physician to hold such medication. Further, something
like ‘Tylenol’ on a patient’s medication record ordered for fever could not be administered by the nurse for a
headache if the patient requested it because that would be ‘practicing medicine without a license’. A nurse
cannot order a social services consult, flush a urinary catheter should it become clogged, refer a patient for
diabetes education, etc., etc., without an order from the supervising physician. Although they were trained to
recognize these things, they carried an independent license, sat for an examination to obtain that license, and
had years of education. Perhaps nurses really could not do any of these things without a supervising physician
to tell them?

Physicians, are critical components of the health care team there is no doubt, but why send a nurse to school
and give him/her an independent license, scope of practice, and make them answerable to a board of nursing
but then limit their usefulness.

In the early years of the nursing profession, it was generally believed that nurses served and cared for their
patients by assisting physicians. However, the perception of nursing often varied dramatically from its
practice. During wars and times of crises, nurses worked with and beside physicians conducting surgical
procedures, diagnosing care, and prescribing treatments and drugs. The role of the public health nurse, as it
developed earlier in this century, was often independent, with nurses working with families of patients with
tuberculosis or other highly contagious diseases and providing a broad range of interventions, both health-
and socially-focused.
During the twentieth century, the nursing profession has undergone immense change. Nurses have developed
themselves as independent professionals with a unique body of knowledge. 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
nondegree, 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.”

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: 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.

Areas of practice: “Nonphysician 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.

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.

 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.

 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.

 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.

Nurses play an integral role in the healthcare industry, providing care to patients and filling

leadership roles at hospitals, health systems and other organizations.

But being a nurse is not without its challenges. It's a demanding profession that requires a lot of
dedication and commitment.

Here are five big issues facing nurses today.

1. Compensation. When it comes to nurse compensation, regional differences are to be expected

based on cost of living.
Nurses living in certain regions of the U.S. make much more than nurses in other regions, according
to the Association of peri Operative Registered Nurses organization.

Beyond regional differences in pay, nurse pay gaps also persist between genders.

Male registered nurses earn, on average, upwards of $5,000 more than their female counterparts. The
gender pay gap is present in all specialties except orthopedics, according to a study published
in JAMA. Among nurse specialties, chronic care had the smallest gender pay gap, at $3,792, and
cardiology had the highest gap, at $6,034.

2. Workplace violence. Another major challenge nurses face is violent behavior while on the job, be
it from patients or coworkers.

Between 2012 and 2014, workplace violence injury rates increased for all healthcare job
classifications and nearly doubled for nurse assistants and nurses, according to data from the
Occupational Health Safety Network. A total of 112 U.S. facilities in 19 states reported 10,680
Occupational Safety and Health Administration-recordable injuries occurring from January 1, 2012,
to September 30, 2014. There were 4,674 patient handling and movement injuries; 3,972 slips, trips
and falls; and 2,034 workplace violence injuries.

This year, North Carolina took a stance against workplace violence. Starting Dec. 1, people who
attack hospital workers in North Carolina could be charged with a felony, thanks to a new state law.
The News & Observer reported that the new law passed by "large margins" and was signed into law
last month.

Other states are also cracking down on workplace violence: In Massachusetts, the Massachusetts
Nurses Association union is pushing a workplace violence bill that would add enhanced plans around
workplace safety.

3. Short staffing. Staffing is an issue of both professional and personal concern for nurses today. In
fact, issues related to staffing levels, unit organization or inequitable assignments are one of the top
reasons nurses leave a hospital job, according to Karlene Kerfoot, PhD, RN, vice president of nursing
for API Healthcare.

Back in June, the Health Policy Commission unanimously approved a mandate on nurse staffing in
intensive care units throughout Massachusetts. The regulations require that nurses in intensive care
units in hospitals, including hospitals operated by the Massachusetts Department of Public Health, be
assigned only up to two patients at a given time. The regulations apply to all ICUs, including special
units for burn patients, children and premature babies.

If staffing is inadequate, nurses contend it threatens patient health and safety, results in greater
complexity of care, and impacts their health and safety by increasing fatigue and rate of injury.

Indeed, a Minnesota Department of Health review of literature found strong evidence linking lower
nurse staffing levels to higher patient mortality, failure to rescue and falls in the hospital. There was
also strong evidence that other care process outcomes such as drug administration errors, missed
nursing care and patient length of stay are linked to lower nurse staffing levels.

Furthermore, a study published in Health Affairs found that inadequate staffing can hinder nurses'
efforts to carry out processes of care. Researchers found that hospitals with higher nurse staffing had
25 percent lower odds of being penalized under the Affordable Care Act's Hospital Readmissions
Reduction Program compared to otherwise similar hospitals with lower staffing.

That's why unionized nurses often bring up staffing levels when they are in the middle of contract
negotiations. For instance, dozens of nurses protested Aug. 3 outside of St. Petersburg (Fla.) General
Hospital over staffing levels and wages. Additionally, nurses and other healthcare workers planned
to hold a picket July 15 outside Renton, Wash.-based Valley Medical Center over staffing levels.

4. Long working hours. Nurses are often required to work long shifts. But in a number of cases,
nurses must work back-to-back or extended shifts, risking fatigue that could result in medical
mistakes.
A 2012 study published in Health Affairs found that the longer the shifts for hospital nurses, the higher
the levels of burnout and patient dissatisfaction. Survey data from the study showed that more than
80 percent of the nurses in four states were satisfied with scheduling practices at their hospital.
However, as the proportion of hospital nurses working shifts of more than 13 hours increased, patients'
dissatisfaction with care increased. Furthermore, nurses working shifts of 10 hours or longer were up
to 2.5 times more likely than nurses working shorter shifts to experience burnout, job dissatisfaction
and intent to leave the job.
And a 2014 study in the American Journal of Critical Care found that nurses impaired by fatigue,
loss of sleep, daytime sleepiness and an inability to recover between shifts are more likely than well-
rested nurses to report decision regret, a negative cognitive emotion that occurs when the actual
outcome differs from the desired or expected outcome.

5. Workplace hazards. Nurses face a number of workplace hazards each day while just doing their
jobs. These hazards include exposure to bloodborne pathogens, injuries, hand washing-related
dermatitis and cold and flu germs.

OSHA estimates 5.6 million out of roughly 12.2 million workers in the healthcare industry and related
occupations are at risk of occupational exposure to bloodborne pathogens.

And rates of workplace injury are higher in healthcare than other industries. Nurses experience more
than 35,000 injuries involving the back, hands, shoulders and feet each year, according to the Bureau
of Labor Statistics. Many things influence the likelihood of injury, including age of the nurse and
environment.

Aside from acute injury, nurses are also likely to suffer harm to their hands. A recent study from the
University of Manchester revealed healthcare workers following hand hygiene protocols are 4.5 times
more likely to suffer moderate to severe skin damage. In the same study, researchers found healthcare
workers made up roughly 25 percent of reported cases of irritant contact dermatitis.

Protecting nurses goes beyond their hands. As cold and flu season nears, hospitals and health systems
can prepare to protect their workforce, including extra measures for those who do not receive the
vaccinations for personal or religious reasons. One option is having the nurses wear an antiviral face
mask, which has been show to kill or inactivate 99.99 percent of laboratory-tested flu viruses.

Lack of involvement of nurses in health and nursing policy formulation and planning
There is insufficient involvement of nurses in health planning
ISSUES IN INDIA (MIDWIFERY)
Workplace health hazards: Nurses are constantly exposed to rigorous physical and mental stress
attributed to abundant workload and also they are not even provided with health coverage. Long
working hours: Majority of the nurses have to work beyond the mandatory 8 hrs shift to more than 12
hrs. Apart from wages, nurses are not given employment benefits and gratuity and working in night
shifts disrupts their work-life balance.

a. Shortage of Staff: As there is evident shortage of the staff in hospitals, nurses has to even perform
non nursing task and this makes the nurse-patient ratio quite poor, and nurses attend patients in more
numbers than they are expected to. Thus in many hospitals the average nurse-patient ratio is quite
higher 30:1 in some cases, whereas the allowed ratio is1:61. As nurses are overloaded with extra
work, it hampers the Patient- Nurse engagement.
b. Lack of Recognition: Nurses, even after pursuing professional status, are n Workplace health
hazards: Nurses are constantly exposed to rigorous physical and mental stress attributed to abundant
workload and also they are not even provided with health coverage. Long working hours: Majority of
the nurses have to work beyond the mandatory 8 hrs shift to more than 12 hrs. Apart from wages,
nurses are not given employment benefits and gratuity and working in night shifts disrupts their work-
life balance.
c. Lack of Autonomy: India a nurse has limited autonomy and authority. In other countries, nurses
play vital role in decision making, but in India it is lacking. ot recognized by others, be it their
superiors or the community, hence this creates a huge gap between how nurses understand themselves
and the way community understand nurses.
. d. Societal Challenges: Nurses are skilled professionals who undergo training and undertake
professional course to attain professional status. Still, they have often been seen by others as unskilled,
morally suspect women who works as servants do. The recognition that they feel they deserve has not
been given to them. This gap between what they are and what other thinks of them has caused a
painful distress among them about status, and has made them quite aware of the injustice of it [4].
e. Ethical Issues: Another aspect that has not been highlighted much anywhere is of human rights in
the form of sexual harassment to them (female nurses). Lack of work place ethics and lack of respect,
with harassment by either doctors or the management by constantly accusing them of dereliction of
duty make it more difficult for them.
f. Lack of Growth Opportunities: In India seats in nursing colleges are increasingly falling vacant
and the annual supply of nurses is short. Furthermore, qualified are eagerly looking for better paid
jobs in richer countries. Most of the nurses migrating to the high income countries come from the
developing countries such as India [5,6]. India with an already dismal health system is suffering more
as nurses are migrating to other countries.
g. Financial Issues: In the private sector, pays are pathetically low and lacks standardization. Many
have to sign a bonded contract that inevitably binds them to that facility and breaking the contract
often involve paying huge amount for obtaining their release. Otherwise, all their certificates are held
by the hospital management.
  BIBLIOGRAPHY
• Basher P. Shabeer, Khan Yasheen S. “A concise text book of advanced nursing practice”, EMMESS
Medical Publishers, first edition 2012, page no. 694-698.
• Kozier B, Erb G, Barman A, Synder AJ. Fundaments of Nursing, concepts, process
and practice, edition 7 2001.
• Potter Perry;S, fundaments of nursing by Jackie crisp, patricia ann potter, 2 nd edition, Annegriffin
perry page no. 143-155.
 JOURNAL
• World Health Organization (2001) Health and human rights publication series, WHO press, geneva
available: www.who.int accessed 19 march 2008.
• A.A.C. Title 9, Chapter 10, Article 8: Hospices; Inpatient Hospice Services. (2003). Arizona
• AAFP. (2008). Guidelines on the Supervision of Certified Nurse Midwives, Nurse Practitioners and
Physician Assistants. Retrieved March 5, 2009, from American Academy of Family
 WEBSITE
• PhysiciansPolicyandAdvocacy:http://www.aafp.org/online/en/home/policy/policie
s/n/nonphysicianproviders.html American Association of Colleges of Nursing. (2004). AACN
Position Statement on the Practice
• www.Wikipedia .com
• www.scribd.com
• currentnursing.com
• www.google.com
 MANIBA BHULA NUSING COLLAGE
BARDOLI

SUB : ADVANCE NURSING PRACTICE

TOPIC : INDEPENDENT PRACTICE ISSUES AND INDEPENDENT MIDWIFERY NURSING

SUBMITED TO SUBMETED BY
ANU BABY KINJAL TANDEL
ASSISTANT PROFESSOR FY MSC NURSING
MEDICAL SURGICAL OBG
MBNC MBNC