CHAPTER 2

• Changing environments
From the 1940’s to the 1970’s the vast majority of nurses were employed by
institutions, usually acute care hospitals. However, many nurses became
disenchanted with the restrictions of institutional work, dissatisfied with
workplace conditions, and a disillusioned with the lack of autonomy given to
the profession. They began to actively seek other ways to exert control over
their work life.
Some used employment agencies or job placement services to find
employment opportunities in different hospitals, with the nurse deciding where
and when she would work. By the 1980s, some nurses became the owners of
agencies that served nurses in this way, using their professional aspirations in
order to create a social enterprise that benefited nurses and their patients.
Some of the disenchantment of this period could be found among
nurses who became increasingly concerned about underserved and
disadvantaged patient populations. Most health care systems were
simply focusing on the patient as someone with a disease process that
need to be treated and released, failing to see the patient as a person
with a family in a given social environment. In response to these types
of unmet patient needs, nurse entrepreneurs set up mental health
counselling centres, clinics in rural areas, adult day care centres for
Alzheimer’s patients, occupational health programmes for mineworkers,
and free clinics for the homeless.
The Time is now!
In a world of global economic and technological change,
interdependent national interests and trade agreements, the
situation I which nurses live and work has changed dramatically.
As governments struggle with escalating health care costs,
cutbacks have been made and seem likely to continue. As health
care consultants and powerful international financial institutions
spread the message to privatise and become competitive,
national helath systes are in a state of transformation.
At present, women have many career choices, many of which can be
more remunerative than nursing. For the profession to attract and
retain the best and the brightest people, it must provide economically
attractive and satisfying positions. Nurse entrepreneurs can help
generate those positions, and promote the establishment of flexible,
autonomous workplaces where nurses can be satisfactorily
compensated. The socio-economic welfare of nurses in an essential
component of a fair workplace, a truth long recognized by ICN as
crucial to the betterment of nursing heath.
The European Commission has taken the position that
entrepreneurship is a driver for economic growth, competitiveness
and job creation. In addition, entrepreneurship is seen as a vehicle
for personal development and a means to resolve social issues,
among which is the preoccupying escalation of health care costs (EC
2003). The Organization for Economic Cooperation and
Development (OECD) publishes a “SME (Small and Medium
Enterprose) and Entrepreneurship outlook” on a regular basis (OECD
2006).
The Women’s Entrepreneurialship Development and Gender Equality
(WEDGE) spearheads the work of International Labour
Organization’s In Focus Programme on Boosting Employment
Through Small Enterprise Development (SEED) in the field of female
enterprise. The SEED network is an online resource for women
setting up their own businesses. (www.ilo.org).
In the UK, the Department of Trade and Industry Small Business
Service published “Strategic Framework for Women’s Enterprise:
Sharing the vision of a collaborative approach to increasing female
entrepreneurship (DTI 2006).
Nurses are in a pivotal position to address health care cost issues
through nurse-led clinics for diseases such as diabetes mellitus and
other chronic illness, geriatric care and community case management
for patients discharged early from hospitals.
According to White and Begun (1998), some of the forces that provide
the impetus for innovative roles include:
• The rise of the ‘knowledge worker;
• Patient populations poorly served by the existing system;
• Greater emphasis on health status of communities;
• Increased use of ‘outsourced’ services by organizations;
• Transformation of licensure laws and professional scopes of practice;
• Workforce redesign and the displacement of nurses;
• Changing attitudes about the nursing profession;
• Dissatisfaction of nurses with changes imposed by employers;
• Direct reimbursement for some nursing services;
• Significant strides in positioning nurses as provides of health services;
• Increasing percentage of woman-owned businesses; and
• New technologies facilitating small, home-based businesses.
Kingma (1998) pointed out that the majority of the socio-economic
factors that have brought about changes in the health sector and its
environment have also supported the development of innovative
approaches to health care delivery, one of which is nurse
entrepreneurship. Of particular importance among these social and
economic factors are:
• An economic crisis that favoured decentralization and
implementation of innovative cost-effective approaches, including
entrepreneurship;
• World focus on privatization;
• Liberalisation of trade in services, including international (e.g. regional
trade blocs, international trade agreements);
• Facilities for entrepreneurial projects,i.e. information networks,
legislation,public expectations, credit access (especially for women);
• Changes in societal perceptions of authority;
• Higher level of basic education and easier access to further education;
• Increased consumer awareness and changing demands, including in
health matter;
Figure 1: NURSING ENTREPRENEURSHIP and ITS EVOLUTION
PRINCIPLES OF ENTREPRENEURSHIP
PRINCIPLES OF NURSING

Legal and Ecomic Context

Nursing Entrepreneurship
Nurse entrepreneurship are found in all three economic systems market driven, mixed
and even the public sector. For example, nurse midwives within the public health
systems have been allowed to practice as independent entrepreneurs for many decades
already. And there is a growing trend of independent practice being purchased by the
public sector and funded by public monies, thus promoting the development of
entrepreneurship in a public health system.
Prevalence
Statistical data on nurse entrepreneurs is difficult to obtain and compare, as different
definitions are used. In some cases, private duty nurses are included, in others they are
not. In certain countries, nurses owning business and employing staff are no longer
considered nurses and cannot be identified as such in the statistical data. In general,
however, it appears that 0.5%-1% of working nurses are nurse entrepreneurs. The
geographic distribution of nurse entrepreneurs is also uneven. Their presence is
influenced by public demand, the legal right to practice, provisions for direct third party
reimbursement(i.e health insurance), and access to support services.
Certain obvious exceptions exist, however. Nurse midwives have had
the possibility to practice independently in many countries since the
beginning of the last century, and their legal status has never been
challenged. Their long experience with independent practice has
encouraged and supported many experienced graduates to become
entrepreneurs.