DR. D.Y.

PATIL VIDYAPEETH, PUNE

(Deemed to be University)

(Accredited by NAAC with a CGPA of 3.64 a four-point scale at ‘A+

+’grade)
DR. D.Y. PATIL COLLEGE OF NURSING
PIMPRI, PUNE-411018

SEMINAR ON
‘’ INDPENDENT PRACTICE
ISSUES’’
( ADVANCED NURSING PRACTICES )

SUBITTED TO : DR. MRS. KAVITA KELKAR

SUBMITTED BY : MS. SIYONA BANSODE

(MSC NURSING SEM - I)
SUBMITTED ON : / 09 / 2023
Name Of The Student : Ms. Siyona Bansode

Name Of The Guide : Dr. Mrs. Kavita Kelkar

Name Of The Course : M.Sc. Nursing Sem I

Name Of The Subject : Advanced Nursing Practices

Name Of The Topic : Independent Practice Issues

Group MSc Nursing Sem I

Date : / 09/ 2023

Time: 45 minutes

Venue : DR. D.Y.P. College Of Nursing, Pimpri, Pune -

411018.

Method Of Teaching : Lecture cum Discussion

A.V. Aids : Chart Paper, Handouts, PPT

Previous Knowledge Of The Group : Group has the previous knowledge

of different types of availability of courses for the Registered Nurses .
General Objectives :
At the end of the seminar the group will be able to perceive in depth the knowledge regarding
s and will be able to apply this knowledge in future nursing practices.

Specific Objectives :
At the end of the class students will be able to :

 Define Independent Nurse Practioner.

 Enlist the courses available for Independent Nurse Practioner.
 Analyze the issues faced by the nurses during independent practices .

Outline :
 Introduction
 Definition
 Philosophy Of INP
 Historical Development Of INP
 Key Issues To Consider Professional Issues
 The Process Of Independent Nurse Practioner
 Educational requirements for INP
 Independent Courses For Nurse Practioner
 Responsiblities of INP
 Courses available for INP
 Issues of INP
 Summary
 Conclusion
 Bibliography
  INTRODUCTION :
Changes in health care and nursing profession have provided nurses with more opportunities
to apply expertise independently.
The government recognizes significant expansion in tertiary care services both in public and
private health sectors. In building their capacity, it is highly significant that the health care
professionals require advanced educational preparation in specialty and super-speciality
services. To support specialized and super-specialized healthcare services, specialist nurses
with advanced preparation are essential. Developing training programs and curriculum in the
area of tertiary care is recognized as the need of the hour. Nurse practitioners (NPs) will be
able to meet this demand provided they are well trained and legally empowered to practice.
With establishment of new cadres and legal empowerment, master level prepared NPs will be
able to provide cost effective, competent, safe and quality driven specialized nursing care to
patients in a variety of settings in tertiary care centres. Nurses who are self employed are
reffered to as independently practicing. Although independent practice face some unique
challenges.

 DEFINITION :

 According to American Academy of Nurse Practioners :

“An Independent Nurse Practioner is reffered 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.”
 According to The International Council Of Nurses :
An Independent Nurse Practioner is 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. It’s
care focuses on patient’s conditions as well as the effects of illness on the lives of the
patients and their families.
 INP’s 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, INP’s conduct research and are often active in patient advocacy
activities.
 HISTORICAL DEVELOPMENT OF INP :

 1965 :
Dr. Loretta Ford and Dr. Henry Silver develop the first nurse practioner (NP) program
at the University Of Colorado.
 1967 :
Boston College initiates one of the earliest master’s program of NP.
 1968 :
Directed by a nurse and physician team, the Boston based Bunker Hill/ Massachuttess
General Nurse Practioner Program begins.
 1973 :
More than 65 NP programs exisit in the U.S.
National Association of Peadiatric Practitioners (NAPNAP) is established.
 1978 :
The Association Of Facultiies And Paediatric Nurse Practioners (AFPNP) is
established and begins developing PNP curriculum.
 1985 :
The American Academy of Nurse Practioners (AANP) is established.
 1987 :
AANP conducts a member survey regarding NP professional malpractice liability
insuarance coverage, assisting NPs in re-establishing affordable malpractice
insurance.
 1989 :
Publication of the Journal of the American Association Of Nurse Practioners
(JAANP) begins.
 2019 :
AANP builds and moves into its first fully owned corporate headquartes in Austin,
Texas. AANP surpasses 100,000 members.

 KEY ISSUES TO CONSIDER PROFESSIONAL ISSUES:

 Conflict Of Interest :
Primary obligation is providing professional care to his/her clients.
In a position of trust and cannot use their position to influence their clients for
financial gain of non financial benefit.
Avoid selling products or services to clients they are treating.
Avoid conflict of interest situations in their practice, particularly when it comes to
the endorsement and advertising of products.

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

 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 a description of services and nursing
credentials, practice experience, fees, address and phone number.

 Fees :
According to Nursing Act 1991
Submitting an account or change for services that the member know false or
misleading.
Failing to fulfill the terms of an agreement for professional services.
Changing a fee that is excessive in relation to the service for which is charged.
Offering or giving a reduction for prompt payment of an account.
Before setting fees, a nurse should research the fees of other nurses who have
similar qualification and experience and who provide comparable services.

 Informed Consent :
Nurse in independent practice are expected to obtain informed consent before
performing any treatment.

 Documentation:
Health records are the means by which information about the client is
communicated the health care team and how continuity of care is maintained.
They also demonstrate the nurses accountability and answer questions about the
type of care provided.

 Confidentiality System :
Nurse in independent practice requires to maintain the confidentiality of the client
information and cannot communicate the information to another person unless the
client or client’s representative gives consent or it is required by law.

 Other Issues:
 Bussiness or legal Council:
 Nurses may want to seek legal advise before starting and independent nursing
practice.
 Liability of Protection :
The college recommends that nurses in independent practice purchase liability
protection to enable public redress if any problems occurs.
 Networking:
Entrepreneurial support groups for self employed nurses offer assistance with peer
feedback, idea and issue sharing, planning for vacation and sickness etc.

 THE PROCESS OF INDEPENDENT NURSE PRACTIONER :

 Novice :
In the beginning a nursing student, or any nurse entering a situation in which there
is no previous level of experience, for example, an experienced operating room
nurse chooses to practice in home health. The learner learns via specific set of
rules or procedures, which are usually linear.

 Advanced Beginner :
A nurse who had some level of experience with the situation is termed as an
advanced beginner. This experience may only be observational in nature, but the
nurse is liable to identify meaningful aspects of or principles of nursing care.

 Competent :
A nurse who has been in same clinical position for 2-3 years. This nurse
understands the organization and specific care required by the type of clients. E.g.
Surgical, oncology or orthopaedic clients. This nurse is a competent practioner
who is able to anticipate nursing care and establish long range goals. In this phase,
the nurse has usually had experience with all types of psychomotor skills required
by this specific group of clients.

 Proficient :
A nurse with greater than 2-3 years of experience in the same clinical position will
be proficient in that setting. This nurse perceives a client’s clinical situation, and
can transfer knowledge gained from multiple previous experiences to a situation.
This nurse focuses on managing care opposed to managing and performing skills.

 Expert :
A nurse with diverse experience who has an imitative grasp of existing or
potential clinical problem is termed as an expert. The nurse is skilled at
identifying client centered problems, as well as problems related to healthcare
systems or perhaps the needs of the invoice nurse.
 EDUCATIONAL REQUIREMENTS FOR NURSE PRACTIONERS:

 Pursue a bachelor of science in nursing ( BSN/ B.Sc. Nursing ) from an

accredited program ( 4 years).
 Become a registered nurse (RN) and get experience in a concerned
speciality (1-2 years).
 Get proper regional licensure and speciality certification.

 REPONSIBLITIES IF INDEPENDENT NURSE PRACTIONER :

The responsibilities of a nurse practitioner (NP) depend largely on that

person’s specialization and the state in which he or she practices. According to the
American Association of Nurses Practitioner (AANP), NP’s give primary, acute, and
specialty healthcare services to diverse populations.
With their advanced clinical training, NPs are authorized to diagnose illnesses,
treat conditions and provide evidence-based health education to their patients. NPs
assess their patients by examining medical histories, performing physical evaluations
and ordering (or performing) diagnostic tests.
Diagnosis – paying thought to the unique risk factors and needs of individual
patients and their families- and develop individualized treatment plans, follow up on
courses of treatment, collaborate with other healthcare professionals and maintain
detailed records.
Continuing education (CE) to keep abreast of technological, methodological
and other developments in their field.
NP’s serve not only as healthcare providers to patients, but also as mentors,
counselors, researchers, educators and consultants.
Specific responsibilities are listed below
 Taking verbal patient histories
 Ordering and interpreting diagnostic tests, including labs and imaging
 Prescribing medication
 Administering immunizations
 Developing and managing treatment plans
 Performing in-office procedures
 Treating minor injuries
 Diagnosing acute and chronic illnesses
 Developing policies
 Educating and counseling patients

 INDEPENDENT COURSES FOR NURSE PRACTIONERS:

  Adult Nurse Practioner
 Family Nurse Practioner
 Pediatric Nurse Practioner
 Acute Care Nurse Practioner
 Geriatric Care Nurse Practioner
 Psychiatric And Mental Health Nurse Practioner
 School Health Nurse Practioner
 Family Nurse Practioner
 Midwifery Or Women’s Health Practioner
 Nurse Practioner In Critical Care

 INDEPENDENT NURSE MIDWIFERY PRACTIONER :

 Introduction :

Midwifery term is used to describe the activities of health care providers who are
experts in the women health care including prenatal care to expectant mothers,
attending at birth and providing post-partum care to mother and her infant.
Practitioners of midwifery are known as midwives.

 Definition :

Independent midwifery practice enables registered nurse midwives to utilize their

knowledge skills, judgement and authority in the provision of midwifery practice
package and primary women's health services while maintaining accountability
for the management of patient care in accordance with midwifery standards laid
down by the midwifery or nursing council of their country. Independent should
not interpreted to mean alone, as there are clinical situations when any prudent
practitioner would seek the assistance of another qualified.

 Midwifery Practice Package For Independent Practice:

1. Access to a midwife 24 hours a day, 7 days a week.

2. Two midwives available alternatively and provide women centered antenatal,
intrapartum and post-natal midwifery care.
3. Antenatal care in privacy.
4. Continuity of care throughout labour.
5. Post-natal care up to 6 weeks.
6. Knowledgeable breast-feeding support.

 Standard required for the practice of Midwifery :

Midwifery practice as conducted by midwife is the independent management

of women's health care, focusing particularly on pregnancy, child birth the post-
partum period care of new born, family planning and gynaecological needs of women.
 Midwives provide consultation, management, collaborative management or referral as
indicated according to standards of midwifery practice.
In India as such standards of midwifery practice act are not developed to do
independent midwifery practices which are one of the essential requirements.
American college of nursing midwives has defined eight standards of practice.

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, collaboration and
referral.
 Uses community services as needed.
 Demonstrates knowledge of the medical, psychological, economical, cultural and
family factors that affect care.
 Demonstrates appropriate techniques for emergency management including
arrangements for emergency transportation.
 Promotes involvement of support persons in the practice settings.

Standard - III
 The midwives practices in accordance with the philosophy and the code of ethics of
the professional body provides clients with a description of the scope of midwifery
services and information regarding the client's rights and responsibilities.
 Provides clients with information regarding services when requested or when care
required 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 judgement that foster the
delivery of safe satisfying and culturally competent care.
 The midwife collects and assesses client care data, develops and implement
individualized plan of management and evaluates outcome of care.
 Demonstrates the clinical skills and judgements described in the basic
midwifery practice.
 Practices in accordance with standards.
 Practices in accordance with service or practice guidelines that meet the requirements
of the particular institution or practice settings.

Standard – V
 Midwifery care is based upon knowledge, skills, 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
a) Client selection criteria
b) Parameters and methods for assessing health status.
c) Parameters for risk assessment
d) Parameters for consultation, collaboration and referral.
e) Appropriate 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 communications and institutions.
 Provides prompt and complete documentation of evaluation, course of management
and outcome of care.
 Promotes documentation system that provides for confidentiality and transmissibility
of health records.
 Maintain confidentiality in verbal and written communications.

Standard – VII
 Midwifery care is evaluated according to an established programme for quality
management that includes a plan to identify and resolve problems.
 The midwife 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 competencies to incorporate
new procedure that improve care for women and their fames.
 The midwife identifies the need for new procedure taking into consideration
consumer demand, standards for safe practice and availability of other
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, experience, advanced skills and competency.
 Direct entry midwife programme to create a new category of professional midwife.
These midwives will work exclusively for maternal care.
 The midwifery profession should identify, develop and implement mechanism to
recruit midwives who reflect Indian population with their competencies.
 It is needed to develop categories of midwives as per their expertise in their
midwifery.
 CRITICAL CARE NURSE

 Introduction :

Critical Care Nurse Practitioner Program is intended to prepare registered BSc

Nurses to provide advanced nursing care to adults who are critically ill. The
nursing care is focused on stabilizing patients’ condition, minimizing acute
complications and maximizing restoration of health. These NPs are required to
practice in tertiary care centers. The program consists of various courses of study
that are based on strong scientific foundations including evidenced based practice
and the management of complex health systems. These are built upon the
bachelor’s program in nursing. When authorized by the nursing regulatory
council/s, state or national laws, they may prescribe drugs, medical equipment and
therapies. The NPs in CC when exercising prescriptive authority or drug
administration as per institutional protocols, they are accountable for the
competency in
a) Patient selection/admission into ICU and discharge
b) Problem identification through appropriate assessment
c) Selection/administration of medication or devices or therapies
d) Patients’ education for use of therapeutics
e) Knowledge of interactions of therapeutics, if any
f) Evaluation of outcomes and
g) Recognition and management of complications and untoward reactions.

The NPCC is prepared and qualified to assume responsibility and accountability

for the care of critically ill patients under her care.
The said post graduate degree will be registered as an additional qualification by
the State Nursing Council.

 Philosophy

 Indian Nursing Council believes that there is a great need to establish a postgraduate
program titled Nurse Practitioner in Critical Care to meet the challenges and demands
of tertiary health care services in India which is reflected in the National Health
Policy (NHP draft document 2015) in order to provide quality care to critically ill
patients and families.
 INC believes that postgraduates from a residency program focused on strong clinical
component and competency based training must be able to demonstrate clinical
competence based on sound theoretical and evidence based knowledge. Education
providers/preceptors/mentors must update their current knowledge and practices.
Medical faculty/preceptors are invited to participate in this training more in the initial
period of training.
 INC also believes that a variety of educational strategies can be used in the clinical
settings to address the deficit of qualified critical care nursing faculty. It is hoped to
facilitate developing policies towards licensure and create cadre positions for
appropriate placement of these postgraduate critical care NPs in tertiary care centers.
  An educational framework for the NP curriculum is proposed (Figure 1).

 Aim :
The critical care NP program prepares registered BSc nurses for advanced practice roles as
clinical experts, managers, educators and consultants leading to M.Sc degree in critical care
NP.

 Objectives :
On completion of the program, the NP will be able to :
1. Assume responsibility and accountability to provide competent care to critically ill patients
and appropriate family care in tertiary care centres.
2. Demonstrate clinical competence / expertise in providing critical care which includes
diagnostic reasoning, complex monitoring and therapies 3. Apply theoretical, patho-
physiological and pharmacological principles and evidence base in implementing therapies /
interventions in critical care.
4. Identify the critical conditions and carry out interventions to stabilize and restore patient’s
health and minimize or manage complications
5. Collaborate with other health care professionals in the critical care team, across the
continuum of critical care.
  Program Description

The NP program is a Nursing residency program with a main focus on Competency

based training.
The duration is of two years with the curriculum consisting of theory that includes
core courses, advanced practice courses and clinical courses besides clinical
practicum which is a major component.

 Standards/Requirements to start the NP program :

The teaching institution must accept the accountability for the NP program and its
students and offer the program congruent with the INC standards. The hospital should be
a parent tertiary care centre with a minimum of 500 beds and above having Medical ICU,
Surgical ICU, Cardio/thoracic ICU and Emergency care unit with a minimum of 10 beds
and above in each ICU, to a total of 40-50 ICU beds in the hospital.

 ISSUES OF INDEPENDENT NURSE PRACTIONER:

 An inadequate national nursing midwifery education plan and development.

 Shortage of qualified nurse educators.
 Limited role and authority of INC in nursing development.
 Lack of positions at State and National levels.
 Limited active involvement of professional organization.
 Inadequate motivation to provide effective care.
 Non-creation of posts for clinical nurse specialist
 Insufficient nurse specialist and nurse practioner.
 Inadequate standards and guidelines for nurse practioners.

 SUMMARY :

 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 good care of patients. Nurses are responsible for knowing the
laws that apply to their areas of nursing practice.

 BIBLIOGRAPHY :
 Jones L. In-patient nurse practioners. 1985. 48-92
 Hooker,R,Cypher D, Sekscenski E. Patient satisfaction with physician
assistant, nurse practioner and physician care, A method survey of
Medicare beneficiaries. J Clin Outcomes Manage. 2005; 12 (2) : 88-92
 http://nurse-practioners-and-physicianassistants.advancedweb.com/
features/articles/establishing-an-independent-nurse-practioner-
practice.aspx
 Advanced Nursing Practice By Shebeer P. Basheer & S. Yaseen Khan
publication of EMMESS p.694 – 699
 Textbook of Advanced Nursing Practice By Navdeep Kaur Brar & Rawat
p. 975 – 983
 Advanced Nursing Practice By Neelam Kumari publication of Pee Vee p.
744 - 754