Seminar on

Independent Nurse
Practitioner & Midwifery

Submitted To: Submitted By:

Dr. Navaneetha, Priya.A

Head of the Department, Msc Nursing
Community Health Nursing, 1st year
CON, PIMS CON, PIMS

Submitted on:

OBJECTIVES
General Objectives:
 Student will be able to understand the concept of independent nurse practitioner and
midwives and develop desired attitude, and skill for the independent nurse practitioner and
midwifery.

Specific Objectives:
Students will be able to
 Define independent nurse practitioner
 Explain historical background of nurse practitioner
 Key components in independent nurse practitioner
 Describe the process of independent nurse practitioner
 Explain education criteria for independent nurse practitioner
 List down various areas of independent nurse practice
 Describe issues in India regarding INP.
 Enlist the scope of practice
 Define independent nurse midwifery practitioner
 Enumerate the standards required for the practice of midwifery.
 Explain the challenge for Indian midwives.
INTRODUCTION
Changes in the health care and nursing profession have provided nurse with more
opportunities to apply their expertise independently. Nurses who are self employed are
referred to as independently practicing. Although ,they are still bound by all nursing
legislation and standards, nurses in independent practice face unique challenges.
DEFINITION:
According to American Association of nurse practitioners (AANP 2016), Nurse
practitioners are licensed, autonomous clinician focused on managing people’s health
condition and preventing disease.
An independent Nurse practitioner is defined as, “ A registered nurse who provides
professional nursing services as a proprietor of a business, through direct patient care,
education, research, administration or consultation”
HISTORICAL BACKGROUND OF NURSE PRACTITIONERS(NP)
1965*
Dr .Loretta Ford and Dr . Henry Silver develop the first nurse practitioner (NP) program at
the University of Colorado.
1967
Boston College initiates one of the earliest master's programs for NP
1968
Directed by a nurse and physician team, the Boston-based Bunker Hill/Massachusetts
General Nurse Practitioner Program begins.
1973
More than 65 NP programs exist in the U.S.
National Association of Paediatric Nurse Practitioners (NAPNAP) is established
1978
The Association of Faculties and Paediatric Nurse Practitioners (AFPNP) is established and
begins developing PNP curriculum.
1985
The American Academy of Nurse Practitioners (AANP) is established.
1987
AANP conducts a member survey regarding NP professional malpractice liability insurance
coverage, assisting NPs in re-establishing affordable malpractice insurance.
1989
Publication of the Journal of the American Association of Nurse Practitioners (JAANP)
begins.
2019
AANP builds and moves into its first fully owned corporate headquarters in Austin, Texas.
AANP surpasses 100,000 members.

INDEPENDENT PRACTICE ISSUES

Key practice components to consider the scope of service

When defining independent practice, a nurse needs to clearly identify that he or she is
providing nursing services, the extent of those nursing services and under what conditions he
or she will refer clients to other health care professionals. Like all nurses, nurses in
independent practice must maintain the high standards of nursing and uphold the public trust
that has been bestowed on the nursing profession.

Conflict of Interest
A nurse's primary obligation is providing professional care to his or her clients.
Nurses are in a position of trust and cannot use their position to influence their clients for
financial gain of non-financial benefit. Nurses should avoid promoting personal interests,
such as selling products or services to clients they are treating. Selling products may give the
appearance of fulfilling the nurse's personal interests over the client's needs. It is critical that
nurses in independent practice 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 service is closely linked to conflict of interest.
Endorsement occurs when a nurse uses her credentials to lend credibility to a commercial
product, 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 ot sell any foot care
products to her client.

Advertising
There are limitations on how a nurse can advertise his or her services. 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.
Practice guideline independent practice fees
The college does not determine or approve specific service fees. According to Nursing
Act 1991 and the accompanying regulations, the following activities related to fees are
considered professional misconduct.
 Submitting an account or charge for services that the member knows is false or
misleading.
 Failing to fulfil the terms of an agreement for professional services.
 Charging a fee that is excessive in relation to the service for which it is charged and/or
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
qualifications and experience, and who provide comparable services.

Informed consent
Nurses in independent practice are expected to obtain informed consent before
performing any treatment. For consent to be valid, it must relate directly to the treatment.
Treatment is defined as anything that is performed for a therapeutic, preventive, palliative,
diagnostic, cosmetic or other health related purposes, and includes a course or plan of
treatment.

Documentation
An integral part of service that a nurse provides is creating and maintaining accurate
and complete health records and documentation. Health records are the means by which
information about the client is communicated to the health care team and how continuity of
care is maintained. They also demonstrate the nurse's accountability and answer questions
about the type of care provided.

Confidentiality
Nurses in independent practice are required 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 and resources incorporation

Regulated professionals may incorporate their independent practice under legislation.
Business or legal council
Nurses may want to seek legal advice before starting an independent nursing practice.
Liability protection
The college recommends that nurses in independent practice purchase liability
protection to enable public redress if any problem 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

1. 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 a specific set of rules or procedures, which
are usually linear.

2. 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.

3. 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 practitioner 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.

4. 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 as a whole is able to
asses an entire 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.

5. 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 system or perhaps the needs of the novice
nurse.
EDUCATIONAL REQUIREMENTS FOR NURSE PRACTITIONERS
• 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 specialty (1 – 2
years).
• Get proper regional licensure and specialty certification

THE RESPONSIBILITIES OF A NURSE PRACTITIONER (NP)

 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 Nurse Practitioners (AANP), NPs 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.
NPs 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 counselling patients
SCOPE OF NP
 Family practice clinics
 Paediatric clinics
 Specialty clinics
 Nursing homes
 Rehabilitation centres
 Schools
 Emergency rooms
 Urgent care treatment centres

Various Areas of Independent Nurse Practice

 Adult nurse practitioner

 Family nurse practitioner

 Paediatric nurse practitioner Acute care nurse practitioner

 Geriatric nurse practitioner

  Psychiatric and mental health nurse practitioner

 Midwifery or women's health nurse practitioner

 School health nurse practitioner

 Family nurse practitioner

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.

INDEPENDENT NURSE MIDWIFERY PRACTITIONER

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.

STANDARDS 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.

Challenge for Indian midwives

Independent midwifery practice is one of the measures and challenges to assist in

reduction of maternal death. Indian profession of midwifery is facing challenges to make this
dream reality. The challenges are
1. Practice challenges

Following recommendations can be made by midwifery Professional body such as

TNAI to health care system administrators and policy makers and other regulatory bodies to
ensure that practice structures are to be designed to provide the best health care possible by
making the midwifery model of care readily available to women.

 Midwives should be recognized as independent practitioners with the rights and

responsibilities regarding scope of practice, authority and accountability that all
independent by share.
 Health organizations should use to allow quality and standard based midwifery care.
 Midwives should ensure case consultation collaboration and referral provided to a
woman without interruption and for overall benefits.

2. Challenges for law regulation

The regulation and credential of midwives are challenging. Developing laws and regulations
would permit full access to independent midwifery services while protecting the public and
unnecessarily limited midwives with the scope of practice can be avoided. For this: -

 State regulators should enact laws which are based on entry to practice standards on
successful completion of midwifery educational programme.
 Health care system should develop privileging and credentialing mechanisms for
midwives that are consistent with the professional standards, recognize midwifery as
distinct from other health care professions and recognize established process that
permits midwives to build upon competencies within their statutory scope of practice.

3. Educational challenge

The current evolution of health care challenged educators to continue to develop quality
midwives to meet the challenging demands of health care system. Following points can be
taken as challenges.

 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.

4. Challenges for research activities

It is required to continually grow and evolve in order to provide evidence-based midwifery

practice which will help to practice independently.

 Analysis of midwifery practice in view of consumers or women who receive care.

5. Challenges for policy makers

Some of the most pressing issue regarding midwifery go beyond the current scope of
regulatory bodies, professional associations, educators and practitioners. Policy makers are to
be convinced for the importance of independent practice. Research efforts have found that
midwifery makes a positive contribution to the health of women and babies.

RESEARCH ABSTRACT
Background
In India, nursing regulation is generally weak, midwifery coexists with nursing, and
88% of nursing and midwifery education is provided by the private health sector. The Indian
health system faces major challenges for health care provision due to poor quality,
indeterminate regulatory functions and lack of reforms.
Methods
We undertook a qualitative investigation to understand midwifery and nursing
education, and regulatory systems in India, through a review of the regulatory Acts, and an
investigation of the perceptions and experiences of senior midwifery and nursing leaders
representing administration, advocacy, education, regulation, research and service
provision in India with an international perspective.
Results
There is a lack of importance accorded to midwifery roles within the nursing system.
The councils and Acts do not adequately reflect midwifery practice, and remain a barrier to
good quality care provision. The lack of required amendment of Acts, lack of representation
of midwives and nurses in key governance positions in councils and committees have
restrained and undermined leadership positions, which have also impaired the growth of the
professions. A lack of opportunities for professional practice and unfair
assessment practices are critical concerns affecting the quality of nursing and midwifery
education in private institutions across India. Midwifery and nursing students are generally
more vulnerable to discrimination and have less opportunities compared to medical students
exacerbated by the gender-based challenges.
Conclusions
India is on the verge of a major regulatory reform with the National Nursing and
Midwifery Commission Bill, 2020 being drafted, which makes this study a crucial and timely
contribution. Our findings present the challenges that need to be addressed with regulatory
reforms to enable opportunities for direct-entry into the midwifery profession, improving
nursing education and practice by empowering midwives and nurses with decision-making
powers for nursing and midwifery workforce governance.

SUMMARY
So far we discussed about NP and midwives , its different aspect and their
responsibilities.

CONCLUSION
Hope it was clear, if you have any doubt you can ask now. Thank you
REFERENCE

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.

Net reference
 http://www.who.int/hrh/nursing_midwifery/films/en/. 
 https://www.nursing.org
 AAFP. (2008). Guidelines on the Supervision of Certified Nurse Midwives, Nurse
Practitioners and Physician Assistants. Retrieved March 5, 2009, from American
Academy of Family 
 WWW.independentnurse.co.uk
 Mayra K, Padmadas SS, Matthews Z (2021) Challenges and needed reforms in midwifery
and nursing regulatory systems in India: Implications for education and practice. PLoS
ONE 16(5): e0251331. https://doi.org/10.1371/journal.pone.0251331