Independent Practice Issues And Independent Midwifery Nursing Essay

Published Date: 23 Mar 2015

The founder of modern nursing has rightly quoted that nursing is the care which puts the person in the best possible condition for nature to either restore or preserve health or to prevent or cure injury.

Nursing has its own entity and ethics which makes it a profession. In response to the rising health needs, the need for independent nursing is the demand of the hour. This concept is readily formulated and implemented in developed countries. This has helped in meeting the consumers' demand for health benefits.

During the twentieth century, the nursing profession has undergone immense change. Nursing has progressed from an occupation to a fully licensed profession, with members that provide a broad range of services independently, and in a variety of professional relationships with other providers. This evolution has changed how nurses are educated, clinically prepared, and how they perceive their role. Starting with turn-of-the-century debates concerning the appropriateness of professional nursing practice, registered nurses began assessing not only their licensure status, but their roles related to other professionals.

In the early years of the nursing profession, it was generally believed that nurses served and cared for their patients by assisting physicians. However, the perception of nursing often varied dramatically from its practiceThe role of the public health nurse, as it developed earlier in this century, was often independent, with nurses working with families of patients with tuberculosis or other highly contagious diseases and providing a broad range of interventions, both health- and socially-focused.

Definition of independent nurse practitioner

Wikipedia Definition, "An independent Nurse Practitioner(INP) is a registered nurse who has completed specific advanced nursing education (generally a master's degree) and training in the diagnosis and management of common as well as complex medical conditions to provide a broad range of health care services."

American Academy of Nurse Practitioners: "An Independent Nurse Practitioner is referred as advanced practice nurse has a master's degree in nursing in the specialized area of her/his interest and licensed to practice in her/his state."

The International Council of Nurses defines INP: "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. Its care focuses on patient's conditions as well as the effects of illness on the lives of the patients and their families.

INPs make prevention, wellness and patient education priorities. This means fewer prescriptions and less expensive treatment.

Informing patients of their health care and encouraging them to participate in decisions central to the care

In addition to care, INPs conduct research and are often active in patient advocacy activities.

Standards required for practice of midwifery

Midwifery care is provided by qualified practitioner, who is registered

Midwifery care occurs in a safe environment with in context of family, community and system of health care.

Midwifery care supports individual rights and self determination with in boundaries of safety.

Midwifery care comprises of knowledge, skills and judgment that foster the delivery of safe, satisfying and culturally competent care.

Midwifery care based up to knowledge, skills and judgment which are reflected in written practice guidelines.

Midwifery care is documented in format that assessable and component.

Midwifery care is evaluated acc. to an established prog. For quality management that include a plan to identify and resolves problem.

Midwifery practices may be extended beyond the set competences to incorporate new procedures, that improves care for women and their family.

HISTORICAL DEVELOPMENT OF INP

Nurse practitioners have provided a healthy partnership with their patients for more than 40 years.

INP role originated as one strategy to increase access to primary care. The following are brief historical background of INP.

The nurse practitioner role had its inception in the mid-1960s in response to a shortage of physicians. The first NP Program was developed as a master's degree curriculum at the University of Colorado's School of Nursing in 1965, founded by Loretta C. Ford, a nursing faculty member and Dr. Henry K. Silver, a pediatrician. Programs were developed across the country to provide additional education for experienced nurses to enable them to provide primary health care services to large underserved populations. The first programs were in pediatrics and they soon spread to many other health care specialties.

During 1970-1971 Federal Legislation recommended Certificate Programme for nurses to deliver primary health care.

Gradually certificate programme shifted to master's degree

In response to health care reform in 1990s 3 INPs programmes were developed to meet the demand of primary care services.

By 1994, 248 programme centres were developed for INP in US.

In 1995, 49000 nurses were employed as INPs.

American Academy of Nurse Practitioner in 1993 developed standard and guidelines for practice of INPs which are still followed.

Today 200 universities and colleges are offering INP programme all over the world.

70,000 nurses are working as INP in US.

Development of Independent nurse practitioner (Independent Nurse Midwifery Practitioner) development in India

The Indian Nursing Council (INC), the parent body of the nursing councils in the country, has rolled out an initiative, which is in the early implementation stage, and has been forwarded for approval to the Union Health ministry.

Independent nurse practitioners trained in midwifery has been introduced to bring down the high Maternal Mortality Rate (MMR) and Infant Mortality Rate (IMR) in rural areas. The National Population policy 2000 includes reduction of maternal and infant mortality as one of the socio-demographic goals to be achieved by 2010. The single most important way to reduce maternal death in India would be to ensure that a skilledhealth professional is present at every birth. Skilled care during childbirth is important because millions of women and newborns develop serious and hard to predict complications during or immediately after delivery. Skilled health professions such as doctors or nurses who have midwifery skills can recognize these complications and either treat them or refer women to health centers or hospitals immediately if more skilled care is needed.

So, in order to ease the impact of the shortage of gynaecologists in community health centres, INC performed a pilot study for the 'Independent Nurse Practitioner Project' in West Bengal at SSKM Hospital's female medical and surgical wards. The project provides an 18 months training in midwifery, besides an additional training in emergency obstetric care to candidates who have completed their BSc in nursing and have two to three years of clinical experience in ob-gyn wards to take care of ANMS in rural sector. These nurses are called independent nurse practitioners as they are trained to prescribe medicines following approved protocols and take decisions independently in absence of gynaecologists.

2 of the 4 trainees have been assigned to a CHC to manage obstetric cases.

The results of the pilot study has been submitted to health ministry and the government of India is currently examining the proposal to extend this project all over India. INC is finalising a curriculum with senior obstetrics and gynaecologists for the training of independent nurse practitioner module.

Explains T Dileep Kumar, president, INC, "In rural areas, though a community health centre should be manned by physician, surgeon, paediatrician and gynaecologist, the community health centre is usually found facing a shortage of gynaecologists. It's in such a scenario, that the role of independent nurse practitioner gains importance, here, Auxiliary midwives are trained. Independent nurse practitioners should be regarded as a part of solution for improving quality, access and cost of care and continuing education."

BASIC requirements of Independent nurse midwifery practitioner

Becoming Independent nurse midwifery practitioner is one of the important challenges as it needs specialized qualification. The basic requirements are mentioned below:

Basic nursing education

Registered nurse

Advance Nursing Certification (Master Degree in Obstetics and gynaecology nursing)

Collaboration with any hospital/agencies for referral and reimbursement

Areas of practice

Independent nurse midwifery practitioners work in a variety of settings, including:

Community Clinics and Health Centres

Nurse managed centres

private practices (either by themselves or together with a physician),

hospitals,

nursing homes,

birthing centers.

Women's Health Clinics

Home health care agencies/Home Nursing

Schools or colleges based health clinics

They often provide care to underserved populations in rural areas or inner-city settings.

What Independent nurse midwifery practitioner can do?

Midwifery nurse practitioner is a registered professional nurse, with a current license to practice, who is prepared for advanced nursing practice by virtue of knowledge and skills obtained through a post-basic or advanced education program of study acceptable to the State Board of Nurse Examiners.

She is prepared to practice in an expanded role to provide primary care to women, to well-woman related to reproductive health, conduct annual gynecological exams, provide education regarding family planning, and provide menopausal care.

She provides care in a variety of settings including, but not limited to homes, hospitals, institutions, community agencies, public and private clinics, and private practice. She acts independently and/or in collaboration with other health care professionals to deliver health care services. She conducts comprehensive health assessments aimed at health promotion and disease prevention. She is capable of solo practice with clinically competent skills and are legally approved to provide a defined set of services without assistance or supervision of another professional.

Midwifery practitioners are specialists in low-risk pregnancy, childbirth, and postpartum. They generally strive to help women to have a healthy pregnancy and natural birth experience. They are trained to recognize and deal with deviations from the normal.

Midwifery nurse practitioners are uniquely qualified to resolve unmet needs in primary health care by serving as an individual's point of first contact with the health care system. This contact provides a personalized, client-oriented, comprehensive continuum of care and integrates all other aspects of health care over a period of time. Their focus of care is on health surveillance (promotion and maintenance of wellness), but it also provides for management of complications in order to maintain continuity.

Midwifery practitioners refer women to general practitioners or obstetricians when a pregnant woman requires care beyond the their' area of expertise. They are trained to handle certain more difficult deliveries, including breech births, twin births and births where the baby is in a posterior position, using non-invasive techniques.

Nurse-midwives work together with OB/GYN doctors. They either consult with or refer to other health care providers in cases that are outside of their experience (for example, high-risk pregnancies and pregnant women who also have a chronic disease).

Many studies over the past 20 - 30 years have shown that nurse-midwives can manage most perinatal (including prenatal, delivery, and postpartum) care, and most of the family planning and gynecological needs of women of all ages. Nurse-midwifery practitioners have improved primary health care services for women in rural and inner-city areas.

SCENARIO OF MIDWIFERY IN USA

INDEPENDENT MIDWIFERY PRACTICE

It is the position of the American College of Nurse-Midwives (ACNM) that midwifery practice is the independent management of women's health care, focusing particularly on common primary care issues, family planning and gynecologic needs of women, pregnancy, childbirth, the postpartum period and care of the newborn. The practice occurs within a health care system that provides for consultation, collaborative management or referral as indicated by the health status of the client.

Independent midwifery enables certified nurse-midwives (CNMs) and certified midwives (CMs) to utilize knowledge, skills, judgment, and authority in the provision of primary women's health services while maintaining accountability for the management of patient care in accordance with ACNM Standards for the Practice of Midwifery.

Independent practice is not defined by the place of employment, the employee-employer relationship, requirements for physician co-signature, or the method of reimbursement for services. Nor should independent be interpreted to mean alone, as there are clinical situations when any prudent practitioner would seek the assistance of another qualified practitioner. Collaboration is the process whereby health care professionals jointly manage care. The goal of collaboration is to share authority while providing quality care within each individual's professional scope of practice. Successful collaboration is a way of thinking and relating that requires knowledge, open communication, mutual respect, a commitment to providing quality

care, trust and the ability to share responsibility.

SCENARIO OF MIDWIFERY IN UNITED KINGDOM

Independent Midwives UK represent the majority of independent midwives in the UK. The organisation is committed to improving maternity provision for all women in the UK and is working with other support, service and professional groups, including the Government, to achieve that objective. Independent Midwives UK also provides professional advice and mutual support for independent midwives.

The former Independent Midwives Assosiation has recently become Independent Midwives UK, an Industrial and Provident Society. The new organisation is a Social Enterprise and with Government support, Independent Midwives UK is working towards making Independent Midwifery available to all women who are entitled to NHS maternity care.

Independent Midwife

Independent Midwives are fully qualified midwives who have chosen to work outside the NHS in a self employed capacity. Independent midwives fully support the principals of the NHS and are currently working to ensure that all women can access 'gold standard' of care in the future ( LINK). The role of the midwife encompasses the care of women and babies during pregnancy, birth and the early weeks of motherhood.

Qualification and regulation of midwives

Midwifery is the most securely regulated profession in the UK. All practising midwives must adhere to the Midwives' Rules which are enshrined in the 1902 Midwives Act of Parliament and subsequent amendments. All independent midwives have undertaken full midwifery training and are subject to annual supervisory visits and equipment checks. In line with the requirements of our regulatory body, the Nursing and Midwifery Council, we are required to ensure that our clinical practice is up to date and that our actions are within our sphere of competence.

Role in emergency conditions

There are very few genuine emergencies during childbirth; this is why research has shown that for most women homebirth is at least as safe if not safer than hospital birth. As the experts in childbirth, midwives are trained to recognise any early warning signs that things may not be progressing normally and to take appropriate action. If the unexpected should happen, all midwives are trained in emergency resuscitation of both mothers and babies Independent Midwives carry all the necessary emergency drugs and equipment and these are checked on a yearly basis by a supervisor of midwives.

Emergency equipments

Independent Midwives carry all the necessary emergency equipment to ensure that if a baby is born needing resuscitation, this can be performed. For example: oxygen, suction, bag and mask. All midwives are trained in emergency resuscitation. Independent Midwives also carry emergency drugs in case a woman is bleeding heavily. They update ourselves on a yearly basis in emergency neonatal resuscitation and many of us have attended emergency skills workshops tailored for independent midwives attending homebirths.

It is a requirement that our equipment is checked on a yearly basis by a supervisor of midwives. As Independent Midwives, often working alone and mainly facilitating homebirth, we are very conscious that we need to be completely up to date with all the necessary skills should an emergency occur.

Charges for services

As Independent Midwives are all self-employed they are all able to choose what they charge. Independent Midwives have to cover all their own costs such as training, equipment and travel. Rates may vary in different areas of the UK; currently a complete package of care will cost you between £2000 and £4500 (approx). Most Iindependent Midwives will want to receive payment in full by the time you are 36 weeks pregnant but if you have genuine difficulties in paying please discuss it with your Independent Midwife as most can offer flexible payment plans.

Credentials to become a midwife

Becoming an independent midwife can seem a daunting challenge but many midwives have taken the leap and few regret doing so. Once a midwife has completed an approved programme of education and is registered with the Nursing and Midwifery Council, (NMC) she/he may practice where ever she/he chooses to in accordance with NMC rules. In the UK that could be in the NHS, the private sector, with an agency or as an independent self employed midwife. If a midwife chooses to be self employed she is regulated by the NMC midwives rules and standards, and must adhere to the same statutory obligations as an employed midwife.

SCENARIO OF MIDWIFERY IN AUSTRALIA

Midwives in Private Practice (MIPP)

For centuries midwives have worked among their communities providing care to women. Historically midwives have held a philosophy of care based on the belief that pregnancy is, basically, a healthy process and a normal part of life, growth and development. It is this belief that guides the way in which midwives in private practice work. Midwives choosing to work privately, rather than being employed by hospitals and other institutions, do so because it allows them to be flexible about the care they provide. That is, the care offered will be in partnership, directed primarily by the wishes of the women and their families.

The private practitioner midwife is able to provide continuity of care to the families who have chosen to use her services. During the pregnancy, the woman and her family develop a friendly supportive relationship with their midwife (in some cases eg homebirth, the care is shared by two midwives). On the day the baby is born the midwife remains with the woman throughout the entire labour. There are no shift changes that require the midwife to leave. During the first week of the baby's life the same midwife visits each day until the baby has settled into a feeding pattern and the parents feel confident in caring for their new baby.

Some midwives in private practice choose to work in specific areas. For example, some may offer postnatal care, or advice with difficult breastfeeding problems (Lactation Consultants) or Maternal and Child Health (M&CHN). In addition, some midwives are skilled and have qualifications in complementary areas such as acupuncture, counselling, naturopathy, chiropractic, massage or homeopathy.

The range of services provided:

Pre-pregnancy advice

Advice about birth options

Childbirth education classes

Sibling preparation classes

Continuous midwifery care during pregnancy

Preparation for and attendance at births in an appropriate environment of the parents' choice

Postnatal care following birth at home, birth centre or hospital

Separate postnatal care for women who want private midwifery care for this period only or who are discharged home early from hospital

Lactation consultancy

Acupuncture and Chiropractic

Referral to and advice about other health professionals such as medical and natural health practitioners, eg obstetricians, paediatricians, GPs, chiropractors, osteopaths, naturopaths, homeopaths

Some midwives have a special interest and expertise in supporting women in special areas such as vaginal birth after caesarean section (VBAC), breech births, water births and postnatal depression.

SCENARIO OF MIDWIFERY IN INDIA

Prof. Uma Handa (ex Consultant Midwife, UNICEF) has a BS and an MSc in Nursing with specialization in obstetrics and gynecology. She has worked in the field of nursing since 1974, in nursing educational institutions in both the conventional and distance system, as well as in national and international health agencies. Countries in which she has worked include Sri Lanka, UK, Bangladesh and South Africa (University of Namibia-UNAM). She has received many special awards throughout her career. Uma's present goal is to promote independent midwifery practice in India to encourage mothers to go through natural childbirth and so that unnecessary medical and surgical interventions can be prevented. Organizations she is member of: Nursing Research Society of India (Founder), Trained Nurses Association of India (TNAI), White Ribbon Alliance India (WRAI), Society of Midwives, and Executive Committee member Birth India.

Issues in independent nurse practice

Nursing has been thought to be a part of the medical 'team' where all professionals provide input to build the best care of the patient but now times have changed nurses have developed themselves as independent professionals with a unique body of knowledge.

The nurses could not document that they hold a patient's medications based on 'nursing judgment'. Such an instance might be when a patient had hypotension from pain medication and thus the morning anti-hypertensive is held. Instead, they need an order from a physician to hold such medication. Further, something like 'Tylenol' on a patient's medication record ordered for fever could not be administered by the nurse for a headache if the patient requested it because that would be 'practicing medicine without a license'.  A nurse cannot order a social services consult, flush a urinary catheter should it become clogged, refer a patient for diabetes education, etc., etc., without an order from the supervising physician. Although they were trained to recognize these things, they carried an independent license, sat for an examination to obtain that license, and had years of education. Perhaps nurses really could not do any of these things without a supervising physician to tell them?

Physicians, are critical components of the health care team there is no doubt, but why send a nurse to school and give him/her an independent license, scope of practice, and make them answerable to a board of nursing but then limit their usefulness.

In the early years of the nursing profession, it was generally believed that nurses served and cared for their patients by assisting physicians. However, the perception of nursing often varied dramatically from its practice. During wars and times of crises, nurses worked with and beside physicians conducting surgical procedures, diagnosing care, and prescribing treatments and drugs. The role of the public health nurse, as it developed earlier in this century, was often independent, with nurses working with families of patients with tuberculosis or other highly contagious diseases and providing a broad range of interventions, both health- and socially-focused.

During the twentieth century, the nursing profession has undergone immense change. Nurses have developed themselves as independent professionals with a unique body of knowledge. Nursing has progressed from an occupation to a fully licensed profession, with members that provide a broad range of services independently, and in a variety of professional relationships with other providers. This evolution has changed how nurses are educated, clinically prepared, and how they perceive their role.

But, there are certain issues in independent practice:

Curriculum for independent nurse practitioner development: Early nurse practitioner training involved nondegree, certificate programs of one year or less. Today the nursing community strongly supports master's degree preparation for entry-level practice. Although the level of education is higher, the focus has remained the same: Nurse practitioner programs emphasize primary care, preventive medicine and patient education.

However, physicians offer a different service to patients. With five years of medical education and three years of residency training, their depth of understanding of complex medical problems cannot be equaled by lesser-trained professionals."

Prescriptive authority. Nurse practitioners have the authority to prescribe and can write prescriptions (including ones for controlled substances) without any physician involvement. However, some believe that there should be collaborative prescribing agreement between nurse practitioners and physicians.

Public view of nursing: Many articles in nursing as early as 1928, speak to the concerns about nurses. "Nice girls, don't do nursing!". "If you have a strong back and weak mind, be a nurse" The public's images of nurses has not essentially changed since nursing's inception. In public opinion, nurses are identified as a means for decreasing the cost of health care. She is considered as "a highly trained professional who is providing an alternative to the expensive primary care physician". They wonder that can she do anything that a primary care physician can do." They are reluctant to recognize nurse practitioners as primary care providers.

Areas of practice: "Nonphysician providers have historically thrived in settings where physicians were unavailable -- places they were unable or unwilling to go," "It remains to be seen if independent nurse practitioners will be economically viable in areas of physician oversupply."

Quality of care: Many studies show that patients have a high or very high level of satisfaction with NP Services.

Regarding measurement of diagnosis, treatment, and patient outcomes, several studies

indicate that the quality of care provided by NPs is equal to that of physicians.

Cost effective care: Nurse practitioners provide a cost effective care. One study compared the costs of care for two primary care problems and found that the cost of care given by NPs was 20% less than the cost of care given by physicians.

At the same time, some argue that, without ready access to supervising physicians, nurse practitioners are likely to order more tests and consultations and be quicker to admit patients to the hospital, thereby driving up health care costs.

Insufficient evidence-based practice and nursing research

There is a need of promotion of evidence-based practice and nursing research so that with a sound knowledge base, the nurses will be able to function more independently.

Establishment of policies on the use of evidence in practice is required. Nurses with a Master's degree should be encouraged to provide evidence, read nursing research and use evidence to improve or change nursing practices. An academic atmosphere should be created in the workplace. An information system and library should be provided. Multidisciplinary research should be encouraged. At the hospital, there should be a person who is responsible for nursing research activity including fund seeking for research and building of research network.

Nurse educators should develop a short-course training on evidence-base and research or to supervise research activity. Resources such as journals and books can be shared. Joint research between nurse educators and clinical staff should be encouraged to strengthen the capacity of both groups and improve education and practice. The INC can be a part of nursing research development. The INC should set nursing research priorities in collaboration with nursing and non-nursing organizations to provide research funds and promote nursing activities for policy formulation. Establishment of a nursing research information system is encouraged to monitor research work, areas of research and researchers. Dissemination of nursing research and models for best practices should be established.

Need for establishment of a continuing nursing education system

Continuing education is an informal study or activity to gain knowledge and learn about new technology. Lifelong education is essential for self-development, knowledge-building and learning. Continuing education stimulates nurses to keep up with new knowledge and technology, to increase their skills and competency, and to be able to contribute to the health care team. The existing continuing nursing education programmes should be strengthened or new units established. The appointment of responsible persons for continuing education activity is needed. Continuing education programmes should get approval from the INC so that nurses can develop increased competency to work independently.

Need to establish a quality assurance system for the nursing service

A quality assurance system comprises vision, mission, objectives, strategic and operational plans, nursing service activity, nursing manpower management, roles and responsibilities, nursing standards, nursing indicators, nursing research, nursing administration and management, resource allocation and financial support.

The objective of this system will be to ensure quality care and nursing outcomes as expected by clients (less suffering, shorter duration of hospital stay, and reduction of health care costs, infection, complications and mortality), and according to professional standards. It also indicates the commitment of the care provider towards providing the best care to consumers. Successful development and implementation of the system depends on the commitment of nursing leaders, hospital administrators, mutual goal-setting, participation of all personnel in the process, continuous quality improvement and good communication.

The role of the INC in regulating nursing practice should be strengthened by amending the Nursing Act to include maintaining of registration of qualified nurses, renewal of licence, and setting up a nursing service and nursing education accrediting system. If possible, a hospital QA system should have nursing as an integral part and involves nurses in a surveyor team.

Thus, this will help ensure the quality of services provided by independent practitioners

Lack of involvement of nurses in health and nursing policy formulation and planning

There is insufficient involvement of nurses in health and nursing policy formulation and planning. Nurses need to know how about how the health care system is structured and how it operates, because it has a significant impact on nursing practice and determines who has access to services and what type of services are available. Knowing the structure of health care system will ensure a reasonable standard of care for all citizens.

In a paper by Dilip Kumar (2005): While focusing on the management of nursing and midwifery services, the paper quotes "Nurses and midwives are not well accepted or recognized as leaders or administrators. Nursing management skills, leadership, lobbying and negotiating skills are poor. There is inadequate number of nurse and midwife leaders at the national and state levels for nursing practice, research, education, management, planning and policy development. Although the nurse is a member of the health team, she/he is never asked to represent the profession in planning and policy formulation for nursing services, education, etc.

So, nurses need to study policy formulation and planning at all levels of education. Techniques for negotiation and lobbying should be taught. Networking within and outside the nursing profession should be built and strengthened. Data and information on nursing and health should be available, updated and accessible online, if possible. The INC should take the lead and actively participate in health policy formulation, especially policies that will affect and impact the nursing profession. More positions for nurses are needed at the policy-decision level.

Autonomy: Nurse practitioners with a Master's degree in advanced nursing practice are authorized to assess patients, make diagnosis, and determine treatment plans. They can also provide education and consultation

Some NPs are are in business with physicians, they both own the business. Some NPs have their own business entity that contracts with physicians to provide services the physicians do not offer themselves. Some NPs have practices that they own without physician involvement other than what is required by state or federal law. In most states, these NPs must pay a physician to be the collaborator (or to delegate the authority to practice medicine or to develop and sign standardized procedures or protocols). If the physician opts out, the business cannot go on unless and until another physician signs up. In states where no physician involvement is mandated, some NPs are truly independent in business.

However, some believe that it's in the patient's best interest, physicians and nurse practitioners to work together in collaboration with each other. They should work together in practices where their skills complement each other. It is best that they share the patient load and divide duties. Together, the physicians and nurse practitioners are much more effective than they are separately. It will also help physician to free him to see the patients who need him the most.

"The best care people can receive is from a team approach of the physician, nurse practitioner and other team members."The focus should be on collaboration (a collegial arrangement) rather than supervision (a subservient relationship).

Reimbursement of services: There is also some resistance to expanding nursing payments by private and public third party payers. But, the nurses should have the opportunity to be compensated for care by third- party insurers. Restriction on reimbursement will result in restricted practice areas for nursing. Allowing third party reimbursement will dramatically increase the demands of such services.

The insurance companies believe that there should be collaboration between nurse practitioners and physicians, so that NPs and NMs can receive reimbursement for the services that they are providing. For many years, federal and state reimbursement policies limited the care nurse practitioners could provide by placing restrictions on the coverage of their services.Medicare once limited coverage to services performed in rural areas and nursing facilities; now nurse practitioners may receive direct Medicare reimbursement regardless of the setting or place of service.

Need to ensure quality of nursing education by strengthening nursing programmes, increasing qualified nurse educators and allocating appropriate resources to maximize efficiency and effectiveness

Education is a key factor for human resource development. With good education, people can learn and earn money. Education programmes should be reviewed intensively and revised.

The INC has set standards and syllabi for all nursing programmes. However, the roles and responsibilities of nurses at each level should be clearly defined, and the curriculum structure and training experience may have to be revised. The Master of Science programme in nursing should focus on advanced nursing practice.

Inspections for nursing education institutions are being carried out by the INC. But, a workshop for inspectors should be held to discuss common issues in nursing education, review the inspection process and revise the inspection criteria and guidelines.

The quality of education depends on the quality of the educators. The teacher for the BSc programme in nursing should be at least a Master's degree holder and have teaching experience as prescribed by the INC. The teacher at the graduate level should do research and publish at least one article every two years. Educators should coordinate closely with the nursing staff in hospitals to achieve education that is relevant to the needs of the service. Educators should collaborate with the nursing service in research and nursing service development. The teaching learning activity should emphasize participatory learning and cultivation of lifelong education.

Infrastructural needs such as a library, information technology system and nursing laboratory should be of good quality. The curriculum should be revised regularly, and alumni and stakeholders should be involved in the process so that the curriculum meets the demands of society.

A nursing development plan should be developed at each nursing institution and at the national level. Effective nursing education management requires planning to develop a group of nursing education leaders with the involvement of policy-makers.

The lacunae in the education system are:

An inadequate national nursing and midwifery education plan and development

Limited involvement of nurses and midwives at the policy level

Shortage of qualified nurse educators

Inadequate infrastructure for nursing education

Too many categories of nursing and midwifery personnel

Limited production of academic work and research.

Limited role and authority of the INC in nursing development

14) Insufficient contribution

Few positions for nurses and midwives at the State and national levels

Inadequate nursing leadership and strategic management

Inappropriate nurse to population/patient ratio

Inadequate preparedness of nurses and midwives

Inadequate recognition of the nurse's status in the healthcare system

Iimited active involvement of professional organizations.

Inadequate number of nursing positions as per the recommended staffing norms

Migration

Insufficient number of nurses with Bachelors' and Master's degrees and in clinical specialties.

15) Limited competency of midwives and nurses

Too many categories of nurses and midwives with overlapping roles

Unclear roles and responsibilities of nurses and midwives

Ineffective clinical preparation and supervision during training

Inadequate continuing education system

Insufficient clinical nurse specialists and nurse practitioners

Inadequate facilities and opportunities for clinical nurse specialists

Non-creation of posts for clinical nurse specialists.

Inadequate standards and guidelines for nursing practice

Ineffective regulation of nursing and midwifery practice

Inadequate infrastructure for nursing and midwifery practice

Inadequate motivation to provide effective care

Society of Midwives, India (SOMI)

Society of Midwives, India (SOMI) is a formally constituted membership based national level professional organization of Registered Midwives which was registered with the Registrar of Societies, Hyderabad on 22 November, 2000. SOMI works with the midwives all over India conducting programs especially to improve the skills and knowledge of nurse-midwives.

Objectives:

Work for high standards of midwifery education and services in India.

Promote research and use of evidence in teaching and practice.

Influence policy decisions for safe child birth.

Strive for independent status of midwives and midwifery profession.

How can SOMI promote Midwifery in India in the coming decade?

Motivating the young Indian nurses from rural and urban areas to focus on maternal care by providing competency based midwifery training, having regulations on their working conditions and personal benefits to improve the status of midwives in the society.

Continuing the efforts and focus by the govt, medical and nursing professional bodies and society to have separate registration and regulation council of midwives to establish midwifery as an independent profession and prepare skilled cadre of midwives.

RESEARCH INPUT

Laurant M, et al did a Cochrane Database Systematic Review on substitution of doctors by nurses in primary care. Nurses' role in primary care has recently received substantial scrutiny, as demand for primary care has increased and nurse practitioners have gained traction with the public. Evidence from many studies indicates that primary care services, such as wellness and prevention services, diagnosis and management of many common uncomplicated acute illnesses, and management of chronic diseases such as diabetes can be provided by nurse practitioners at least as safely and effectively as by physicians. After reviewing the issue, an Institute of Medicine (IOM) panel at Washington, DC 2010.recently reiterated this conclusion and called for expansion of nurses' scope of practice in primary care.

Eibner CE,et al (August 2009) did a study on controlling health care spending in Massachusetts. Research in Massachusetts shows that using nurse practitioners or physician assistants to their full capacity could save the state $4.2 billion to $8.4 billion over 10 years and that greater use of retail clinics staffed primarily by nurse practitioners could save an additional $6 billion.

Courtenay M, Carey N, Burke J.did a national questionnaire survey on independent extended and supplementary nurse prescribing practice in the UK. The objective was to provide an overview of the prescribing practices of independent extended/supplementary nurse prescribers and the factors that facilitate or inhibit prescribing. Nurses are able to prescribe independently from a list of nearly 250 prescription only medicines for a range of over 100 medical conditions or, from the whole British National Formulary as a supplementary prescriber.A total of 756 (87%) qualified independent extended/supplementary nurse prescribers used independent extended prescribing; 304 (35%) used supplementary prescribing to treat a range of chronic conditions (including asthma, diabetes and hypertension); 710 (82%) nurses worked in primary care.. Nurses in primary care reported more continuing professional development needs. These needs included update on prescribing policy and the treatment management of conditions. 32% nurses were unable to access continuing professional development. The continuing professional development needs of independent extended/supplementary nurse prescribers are frequently unmet. It will become increasingly important that these needs are met once nurses are able to prescribe the full range of medicines included in the British National Formulary, limited only by their area of competence.

Conclusion

Access to cost-effective, quality health care is a right of every citizen. NPs provide services for the diagnosis, treatment and management of disease as well as illness prevention and health maintenance. Numerous studies conclude that nurse practitioners perform as well as physicians in their specialty area of practice, in patient diagnosis, management of specific diseases and patient outcomes. NPs have improved access to and affordability of health care by consistently offering high quality and cost effective services. Nurse practitioners should be active partners and providers of health care as they insure delivery of quality health care in cost-effective manner.