Dec 17, 2020, By: Gigi van den Hoef , Susan Hagar
- Given the significant cuts to nursing positions in acute care settings across Canada, a shift in funding is needed to focus on community care and chronic disease management.
- Policy-makers, educators, and health-care leaders need to be informed that self-employed nurses bridge gaps in care.
- The Canadian Association of Self-Employed Registered Nurses, known as CASE RNs, is the only national organization dedicated to nurses in independent practice.
With the increasing rise of seniors and patients with complex health needs in Canada, and a reduction in funding for care in hospitals, there has been a progressive shift from traditional institutionalized care into the home and community (Wall, 2014, 2015). Given the significant cuts to nursing positions in acute care settings across Canada, a shift in funding is needed to focus on community care and chronic disease management as patients are being “sent home too soon with little-to-no community support” (Cleveland, Motter, & Smith, 2019; Leslie, 2015; Wall, 2014, 2015).
Many nurses have identified the unmet needs of our aging population and those with neurological diseases, noting an increased demand on community-based health care and minimal access to professional support, thereby embracing the opportunity to start their own businesses.
Elsewhere in the world, nurses do work in independent practice, for example, in the United States and in Australia (Gardner, Duffield, Doubrovsky, & Adams, 2016; National Nurses in Business Association, 2020). However, in Canada there is a paucity of publications related to nurses working in independent practice or who are self-employed (Graham, 2013).
This nursing grand rounds article will discuss and highlight the history of self-employed RNs and the Canadian Association of Self-Employed Registered Nurses, known as CASE RNs, the only national organization of nurses in independent practice.
Self-employment of RNs is not a new idea. In 2004, the International Council of Nurses (ICN) released a paper entitled “Guidelines on the Nurse Entre/Intrapreneur Providing Nursing Service.” The paper discusses nursing entrepreneurship and how it dates back to the turn of the 20th century. Many nurses were in independent practice: “in 1930 over 60% of all registered nurses in Canada were involved in independent private-duty nursing” (ICN, 2004, p. 7).
In 2012, ICN produced and published a 74-page booklet entitled Handbook on Entrepreneurial Practice: Nurses Creating Opportunities as Entrepreneurs and Intrapreneurs (Sanders & Kingma, 2012).
In Canada, some nurses use entrepreneurship to provide nursing support beyond hospital-centred care, as nurses are also seen as change agents (Wall, 2014, 2015). For nurses thinking of becoming nurse entrepreneurs or self-employed, DeSantis and Scales (2015) describe entrepreneurship as “running a business by devoting the necessary time and effort, assuming the financial, psychic, and social risks, and receiving rewards of monetary and personal satisfaction and independence.” It may be time to explore becoming an entrepreneur if one is “independent, confident, creative and expressive, forward thinking, committed and focused, self-motivated, and able to see things through” (p. 94).
According to numbers analyzed by the Canadian Institute for Health Information (CIHI), an estimated 2,837 RNs are self-employed in Canada (B. Wang, personal communication, June 8, 2020). Nurse practitioners and RNs in Manitoba were not included in this number owing to significant undercoverage in voluntary reporting (B. Wang, personal communication, June 8, 2020). We also reached out to the Canadian Nurses Protective Society (CNPS) and were told, “as CNPS professional liability protection is not required in all provinces and territories, we may not have the most complete statistics for the number of self-employed nurses” (E. Fortier, personal communication, September 17, 2020).
There is reason to believe that the number of nurses working in independent practice is much higher, and that under-reporting occurs because of the way nursing colleges analyze their data. The biggest barrier for nurses to becoming entrepreneurs is that the “general public may not know about or recognize the independent practice of nurses or nursing” (Esposito & Sollazzo, 2019).
In Canada, some nurses use entrepreneurship to provide nursing support beyond hospital-centred care, as nurses are also seen as change agents.
Canadian Association of Self-Employed Registered Nurses (CASE RNs)
CASE RNs was originally launched in 2015 as Independent Practice Nurses Association Canada (IPNAC). The association was granted articles of incorporation by the federal government under the Canada Corporations Act on October 20, 2015. The name was changed to CASE RNs in 2016 to comply with Canadian Nurses Association’s (CNA) requirements within their Canadian Network of Nursing Specialties. Specifically, the term “independent” within CNA refers to nurses in Ontario and Quebec only; thus, a name change was required and took place in May 2016.
CASE RNs was officially launched in June 2016 at CNA’s annual general meeting in Saint John, N.B. However, in 2017 CASE RNs had no membership and failed to maintain the requirements set out by CNA, so it soon became dormant.
In early 2019, the defunct leadership approached Independent Practice Nurses Ottawa (IPNO) to carry forward the mission and vision of CASE RNs. The leadership of IPNO formed a new executive for CASE RNs, established a new national board of directors, and thus IPNO became the Ottawa chapter of CASE RNs.
IPNO was established in 2015 by a group of independent, self-employed nurses and business owners. These nurses meet monthly and work intra-professionally whenever possible, benefitting through shared knowledge and experience. They also work interprofessionally, building their network of nurse colleagues to draw upon, including those in the public health-care system.
They continue to bring their nursing expertise through leadership positions in non-profit associations, and to the community through clinical case management, private duty nursing, mental health support, cognitive therapy, foot care, specialized wound care, ostomy and continence care, and much more. The nursing and business experience among IPNO members have allowed for a seamless relaunch of CASE RNs, and the organization has established a sustainable platform from which to grow and serve its members. Visit the CASE RNs website to learn more about the association and become a member.
Policy-makers, educators, and nurse leaders: a call to action
Policy-makers, educators, and RNs in leadership roles must be made aware of the growing number of nurses who work outside of the current health funding model. These self-employed nurses run successful businesses, and they exist because they bring value to patients and the health-care system by addressing the many gaps in current health-care delivery.
Many people have private health-care insurance that covers nursing services; others are willing to pay for additional services once they understand the inherent value, where government-funded support is inadequate (Hermus, Stonebridge, Thériault, & Bounajm, 2012).
It has been observed that people with private health-care insurance are typically not aware of options for accessing private nursing services. They are not informed of these alternatives for accessing nursing support by their family doctor or emergency department staff, and they do not learn of them during hospitalizations or when visiting community facilities.
Health-care consumers have numerous choices in the community, in addition to provincially funded services. It is a shame that insurance plans are not being accessed by all who qualify. Through the wellness model of nursing care, many people would be able to live at home longer and enjoy improved quality of life.
Policy-makers, educators, and RNs in leadership roles must be made aware of the growing number of nurses who work outside of the current health funding model.
Policy-makers, educators, and health-care leaders need to be informed that self-employed nurses exist. These nurses bridge the gaps in care while contributing to new technology as well as ongoing research and development in the community.
To better support reliable health care, access to self-employed nurses is crucial. In addition, the tax system needs to be updated because exemption for nursing services is inconsistent across the country. For example, in Ontario, providing direct nursing care is tax exempt, but providing nursing staff to institutions or conducting research in the community requires Harmonized Sales Tax to be charged.
Looking to the future
More interconnectivity is required to determine how many nurses work in independent practice, and to better understand the services they provide. Each nursing provincial and territorial college could ask more questions of nurses who work in independent practice to clarify their roles, uplift the profession, and promote nurses as innovators and leaders.
Many nurses seek options outside of hospitals and community-based facilities. They feel they have more to offer their patients and families as an autonomous, self-employed nurse. They will be supported and inspired by CASE RNs and nurse colleagues who have found that working independently through their own business is an excellent option.
Looking to the future, CASE RNs will continue to hold monthly national meetings via webinar and is planning a virtual conference in 2021. All are welcome to join us as we provide education and spotlight the good work of our nurse members who are intentional disruptors, inspired influencers, and tenacious leaders.
We would like to thank L. Jurick, K. Lake, and J. Riley for reviewing the manuscript and providing feedback.
Canadian Institute for Health Information (CIHI). (2020). Health workforce in Canada, 2019 — Quick Stats. Retrieved from https://www.cihi.ca/en/nursing-in-canada-2019
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Gigi van den Hoef, MHS, BSc, RN, CCRP, is a medical science liaison and RN consultant. She is president-elect of the Canadian Association of Self-Employed Registered Nurses.
Susan Hagar, RN, BCPA, is founder and CEO of Nurse On Board, Ottawa, and president of the Canadian Association of Self-Employed Registered Nurses.