S Ieong. Clinical Nurse Specialist Entrepreneurship. The Internet Journal of Advanced Nursing Practice. 2004 Volume 7 Number 1.
Changes in the healthcare industry have created opportunities for clinical nurse specialist (CNS) entrepreneurs. The changes include a shift from provider care to self care, movement of the primary site of care from inpatient setting to outpatient or community settings, the aging of the population, the chronicity of illnesses, and the nursing shortage. CNSs have been eligible for Medicare reimbursement since the passage of the Balanced Budget Act of 1997
Clinical Nurse Specialist Entrepreneurship
Entrepreneurs flourished in the Depression in 1930's and the business era of 1950's. The concept of intrapreneurship originated in late 1970s and early 1980s. In 1980's and 1990's, leading economists on all sides of the political structures were preoccupied with the uncertainties of corporate life. They created new businesses and established new companies at a rate of nearly 600,000 per day 2. The ranks of entrepreneurs grew in 1980s as nurses left hospitals where bureaucracy stifled their innovative ideas, and CNSs desire to have control over their work environment. There is a need for consideration of new opportunities due to the culture of re-engineering, restructuring, and downsizing 3. CNSs are in the midst of redesigning health care systems to integrate interdisciplinary, outcome-focused and cost-effective care 4, 5. Because CNS roles were changed or eliminated in many hospital organizations, many CNSs in career transitions consider establishing independent practice. One way to incorporate the CNS sub-roles of expert practitioner, educator, consultant, and researcher in a way that meets the needs of the changing healthcare environment is for CNS to establish a collaborative or independent practice6.
There are three reasons for nursing as a health profession to offer opportunity for entrepreneurship: (1) Nurses are educated from a holistic perspective and positioned to see the broad picture, (2) the traditional work environment for nurses is being downsized in massive scale, and nurses are faced with alternative employment opportunities, and (3) women as business owners are growing in numbers and are receiving recognition and acceptance as legitimate entrepreneurs7. According to statistics, there are over 3 million female entrepreneurs in United States. Women own more than 25% of sole proprietorship businesses, and that 3 times as many women are starting businesses as men 2.
Entrepreneurs have control over and responsibility for an increased proportion of indirect processes of care in their roles. They plan, organize, finance, operate their own businesses, and they work outside of an organization. An advanced practice nurse (APN) entrepreneur is an individual who identifies a patient's need and envisions how nursing can respond to that need in an effective way, and then formulates and executes a plan to meet that need 8. He or she creates new opportunity in the world of business and assembles the resources necessary to successfully exploit that opportunity- money, people and organization 9. A social entrepreneur is one who conceptualizes, implements, and operates services to influence social change 10. An amateur entrepreneur thinks locally, makes snap decisions, knows the trade, thinks small, and conduct business by the “seat-of-the pants”. A professional entrepreneur thinks globally, makes decisions by consensus, knows the business, thinks big, and conducts business using a business plan10.
Intrapreneurs work for an existing health care system, in which many of the indirect processes of the care delivery system may be controlled and managed by other employees or departments. They function to improve, redesign, and augment an employer's current direct care processes, develop new modes of service or introduce new products and services, and they work within an institutional health care system, a microcosm of the larger arena 11. An APN intrapreneur can facilitate transfer of findings from research, internal evidence and evidence-based product evaluation into practice while assuring that the organization achieves cost-avoidance, cost-reduction, and revenue-generating from activities 10. Intrapreneurship offers nurses a slightly higher level of personal and professional security, but requires the same energy and business-building skills of external entrepreneurship.
Types of CNS Entrepeneurs and Businesses
Nurse entrepreneurship is one of the ways for nurses to increase their visibility, reclaim their power and direct their creativity and determination 3. CNSs as entrepreneurs are creative forces within organization to develop and spawn new approaches to meeting patients' needs, and to increase the quality of patient consultation. There are various types of CNS entrepreneurs in diverse specialties, such as acute care, gerontology, ostomy-wound and home health. There are three types of business structure: Sole proprietorship, general partnership, and corporation: S-corporation, limited liability company, or limited liability partnership 8. To start a business, CNSs need to assess the market and determine the need for service. They need to network with colleagues as well as consult with attorneys and accountants to set up appropriate operation systems 12. Not only do CNSs need to possess excellent interpersonal skills, critical thinking skills, collaboration skills, and credibility, they need to know their passion, learn to be persistent, be patient, and connect with other people 10. According to Czaplewski 13, networking with people is one of the cheapest marketing strategies and can be most effective in advancing the business.
There are over 383 articles on nurse entrepreneurs that can be found in OVID and CINANL. Some of the significant articles on CNS entrepreneurs are as follows. Lukacs & Kelechi developed the comprehensive lower extremity assessment form and established an intrapreneurial foot clinic, which offers routine health services to patients 14. David Woodruff started his own continuing education business, the Ed4Nurses, Inc in 1996, and improves patient care by enhancing the knowledge of staff nurses needed to solve patient care problems. Schulmeister described the challenges of her oncology home-based nursing consultation business 6. Dayhoff & Moore founded the Clinical Solutions, LLC, in 1999, which was developed to provide educational services and products for patients and providers, and strategic planning to improve outcomes of care of adults with chronic diseases. In addition, Kathleen Vollman took her innovative ideas and developed the Vollman Prone Positioner in 1999, and Esther Muscari established Lymphedema Therapies in Charlottesville, Virginia.which prospers into great success. Furthermore, Dailey & O'Brien described how a CNS adds value to home health by improving care, quality of life, satisfaction and costs through establishment of telehealth and entrepreneurship 15, 16, 17, 18.
The NACNS Statement on Clinical Nurse Specialist Practice and Education describes the essential attributes and skills of a CNS, and many of the attributes and skills are the attributes and skills of an entrepreneur 10. The subroles of CNS directly reflect the roles of CNS entrepreneurs. Some of the major roles of CNS entrepreneurs include: leaders, consultants, collaborators, advocates, negotiators, experts in marketing and product presentation, as well as researchers 19. CNS entrepreneurs are experts in designing, implementing, and evaluating innovative interventions. They have a solid foundation in clinical knowledge and techniques of marketing, the coding and billing processes. The care they provided support positive patient outcomes with high level of clinical care. They serve as role models for other personnel in applying advanced clinical skills to patient management. The consulting and collaboration skills of CNS entrepreneurs can assist the organization to mobilize resources to deal with practice or system issues 10. The major characteristics and attributes of nurse entrepreneurs are: visionary, decision maker, problem solver, risk taker, self-starter and good communicators 8. They are self confident, assertive, autonomous, committed, creative, determined, ethical, well-organized, flexible, responsible and persistent20, 21.
Like Benner's novice to expert model, a CNS may start beginning as an amateur entrepreneur to test the waters, but until the CNS embraces the attributes of a professional entrepreneur, it is not likely that the business will grow. Likewise, an intrapreneur may think about a patient care problem with a particular group of patients, but until the CNS incorporates systems thinking into the innovative activities, the CNS will not grow her or his influence in the healthcare organization10.
Advantages and barriers to CNS entrepreneurship
Some of the advantages of entrepreneurship are freedom to focus practice on personal interests, flexible time management, quality of practice under CNSs control, new opportunities for service requests, multiple sources of reimbursement, and enhanced problem-solving skills and self-esteem4. With flexible work hours, CNSs can structure their workload and allow time for various activities.
Major barriers to CNS entrepreneurship include the higher cost of malpractice insurance, inability to obtain hospital privileges for some, skepticism of physicians about the independent role of nurses, statutory limitations, and turf issues among various disciplines8, 22. Other major obstacles to overcome with the start of most new businesses include: Start-up costs for the practice, cash-flow and financing an ongoing practice, accounting practices, billing, and collection of receipts, general and malpractice insurance for the practice and individual providers, and hiring, training, and retraining competent, enthusiastic personnel4.
Nurse entrepreneurship can be very rewarding. It provides financial stability, freedom and flexibility, expert status, and allows nurses to leave a legacy to the profession7. Other positive outcomes related to the culture of entrepreneurship include enhanced patient and staff satisfaction, profit and gains, business prosperity and maturation, economic value of innovation, and enhanced quality of care.
There are several implications of entrepreneurship for advanced practice. Graduate nursing programs may need to incorporate business and practice management concepts and skills into APN education, in response to the need for APN business practice7. Professional implications for CNS entrepeneurs include active participation in national and state nurses' associations in formulation of Nurse Practice Acts, and enhanced knowledge of the scope of independent practice in the state where they practice. More research are needed in comparing the roles and outcomes of CNS entrepreneurs and entrepreneurs in other advanced practice roles such as nurse practitioners, nurse anesthetists and certified nurse midwives. Staying abreast of the latest research and healthcare trends is crucial.
As nurse entrepreneurs enable and empower themselves, they simultaneously enable and empower patients and other nurses. As they exercise more control over their practice and the healthcare resources needed by patients, they increase the choices available to patients, and they make it possible for nurses in traditional practice environments to become more entrepreneurial2. Nurse entrepreneurs are expanding their boundaries and creating new options for patients, nurses and organizations.