ED's Blog

Laurie Janes

Nursing and Independent practice

Laurie Janes, April 23, 2019

Self-employment --- otherwise known as private practice or independent practice, is on the rise among registered nurses (RN) and registered nurse practitioners (NP) in New Brunswick. Registered nurses have completed the necessary process for establishing a self-employed business for many years; among several commonly known independent nursing practices are footcare services and prenatal or other health education services. More recently NPs have expressed an interest in establishing self-employed businesses.

RNs and NPs who wish to become self-employed must maintain their registration/license in order to continue to offer services as a registered member of the nursing profession. NANB’s regulatory work in this area includes review of the proposed independent practice to determine if the hours worked by a nurse member in the self-employed business meet the required nursing practice standards and nursing scope of practice. This is necessary if the RN or NP wishes to use hours worked in a private business for the purposes of maintaining nursing (RN or NP) registration requirements.

NB nursing regulation requires that proposals for self-employment as an RN or NP are reviewed by NANB prior to the start up of an independent practice. Hours worked in the practice without review/approval cannot be submitted for registration renewal. As well, if approval from another organization is required for the RN/NP to work the described hours as self-employed ---evidence of that approval is also required to assure the RN/NP can in fact work the hours described in the practice description provided to NANB.

Recently, independent NPs in New Brunswick were prevented from accessing laboratory and diagnostic imaging services for patients in their private practices. This was very concerning for NPs and RNs in New Brunswick. The intentions of the NPs were good: establish NP practices so that patients in their community who did not have access to a family physician ---could gain access to excellent primary health services via a nurse practitioner.

Challenges related to self-employed NP practice can be different than self-employment for RNs. NP scope of practice is like that of a family physician; therefore, many of the health services that NPs offer to patients are considered insured by NB Medicare. While family physicians are provided a billing number that aligns with utilization and payment of insured services, NPs do not have access to a billing number.

As the number of NP descriptions of proposed self-employed businesses sharply increased in 2017-2019, NANB staff identified several information gaps and trends in documents provided for review.

  • Some RNs and NPs were initiating self-employment prior to review with NANB;
  • Some RNs and NPs did not have a good understanding of insured versus uninsured health services in NB;
  • Many RNs and NPs did not know of supplemental insurance through the Canadian Nurses Protective Society;
  • Some applicants were not aware of restricted practice concerning cosmetology procedures;
  • Some RN and NP applicants (who were employees) did not understand that patient files or other forms that were completed after hours and at home could not be considered as independent practice –and could not be billed for NP compensation;
  • Many applicants (RNs and NPs) do not have a sound understanding of health system billing through NB Medicare for insured services.

In discussions with RNs and NPs wishing to establish businesses to practice nursing, it became clear that RNs and NPs may not have sufficient understanding of NB nursing regulatory requirements and/or processes. To assist nurses, NANB is currently reviewing and updating information, forms and processes related to independent practice. Practice monitoring and auditing are planned future measures of that work.

There is additional necessary work that must be completed to support RN and NP independent practice which includes: basic business education/ support during studies and in the community of practice; clear information/consultation to nurses who are seeking direction from NANB, and ongoing communication/education/discussion with key stakeholders regarding the full scope of nursing practices and how those practices can be best utilized in New Brunswick.