Nursing Perspectives

CONSIDERING PRIVATE PRACTICE AS A HOLISTIC NURSE?
WHAT YOU NEED TO KNOW:

Mary Amdall-Thompson RN, MS, CNS

For over 20 years, the author, a Program Executive for Professional Services at the Oregon Board of Nursing, answered scope of practice questions from all levels of licensees. The increase in concerns raised by Registered Nurses seeking to begin holistic practices in non-traditional settings range from scope of practice issues to the acceptance of complimentary therapies. Inquiries from nurses and other health care professionals regarding nursing practices prompted this essay, an overview of information she gave as an agent for the Board of Nursing.

You want a private practice in holistic nursing, providing complimentary therapies and healing work. You also want to stay out of trouble with your licensing board and avoid conflict with other health care professionals. I have compiled a list of what you need to know to be successful.

Be Clear About Your Scope of Practice: Start by reviewing your Nurse Practice Act and the associated administrative rules adopted by your Board of Nursing. Practice Acts differ from state to state. Most states web sites where you can find the Practice Act and rules. If there isn’t a web site, most states publish their regulations and offer them for a nominal price. The National Council of State Boards of Nursing website at www.ncsbn.org contains the names, addresses, telephone numbers, contacts and other information.

In addition to the Practice Act and rules, many Boards of Nursing have position statements or policy statements that they publish to guide nursing practice in specialty areas or in a particular nursing technique/function. Although these policies do not have the level of enforcement that laws and rules have, they can be very useful. They give you a sense of the Board’s stance on a particular subject and assist you in assessing your risk for engaging in an activity within the practice of nursing. For example: The Oregon State Board of Nursing has a position statement that addresses what activities a Registered Nurse may use as proof of continued competence to qualify for licensure renewal. That position statement specifically mentions complimentary therapies that are both within the practice of nursing and activities that a Registered Nurse may count towards hours of practice to qualify for license renewal. I mentioned this is because some boards of nursing have questioned whether complimentary therapies are within nursing scope of practice.

The Registered Nurses scope of practice does not expand or change with continuing education or additional formal education and academic degrees. The scope of practice for the Registered Nurse in each state is the same. However, considering the diversity in practice settings and nursing specialty areas of practice, competencies within Registered Nurse scope of practice vary from nurse to nurse depending on that nurse’s additional preparation and experience. Additional preparation may be in the area of complimentary therapies. Nursing in traditional settings usually places the nurse in a dependent role. They are unable to perform a number of interventions without orders from an advanced practitioner of nursing (Nurse Practitioner, Certified Registered Nurse Anesthetist or Clinical Nurse Specialist) or physician.

However, there are a number of interventions that are “nursing” in nature and do not require the authorization of another health care professional. While I was employed with the Oregon State Board of Nursing, I received many questions about the scope of practice. Here are some examples:

Q: Once I take a class in a complimentary therapy modality and am nationally certified, can I represent myself as a Nurse Practitioner so I can receive third party reimbursement?

A: Nurse Practitioner is a regulated title and the Board defines the scope of practice. So, you cannot represent yourself as a Nurse Practitioner without Board of Nursing certification. You may still be able to receive third party reimbursement, depending on what the insurance policy for your client covers and the insurer’s evaluation of your authority to provide the service. It is common for insurance companies to call the Board to inquire about the nursing scope of practice as it relates to a particular function. In the case of complimentary therapies, the Oregon Board of Nursing believes that these are within the Registered Nurse scope of practice and have adopted a position statement.

Q: Do I need a referral from a physician to treat my clients using complimentary therapies?

A: No, as long as the treatment you provide is within the definition of nursing practice and does not involve making a medical diagnosis or prescribing medication.

Other Resources to Guide Your Practice: Besides laws, rules and policies from your Board of Nursing, there are other sources that deserve attention. Settings that are licensed by a state agency (hospital, nursing home, home health agency) also have laws and rules. While they should not be in conflict with the rules that guide your nursing practice, it is always possible that they may be more restrictive, which means that you need to be aware of them.

Private practices tend not to be regulated. However, if you wish to become a certain type of entity for the purpose of incorporation, profit sharing etc., there are rules related to those entities for which you may need the services of an attorney to guide you. In some states, your licensing board may require that you register with the Board as well as follow other rules for incorporation. At one time, Oregon required that Nurse Practitioners register as a professional corporation with the Board of Nursing.

Professional Organizations: Should you belong to a professional nursing organization such as holistic nursing? It is your personal and professional choice whether or not you seek membership in nursing organizations. There are benefits to doing so. Membership will assist you in networking with other professionals who have interests similar to your own, that will help you stay current in the trends of your chosen specialty. Nursing organizations may also provide you access to a national complementary therapies certification programs, such as parish nursing, guided imagery and holistic nursing. There are other advantages to national certification in a certain specialty. While not necessarily qualifying you for advanced practice status, it does demonstrate to your clients, professional colleagues and other entities that you have achieved competence through a standardized method. These methods usually include formal training, experience and examination.

Malpractice Insurance: If you are in private practice, there is always the chance that you will be sued. You don’t have the umbrella of malpractice coverage that you have if you work for an organization. Malpractice insurance does not have to be expensive and to have it is more than a just a little “peace of mind.” Check advertisements in nursing journals and compare both costs and coverage, paying close attention to the limitations. I would especially check to see if there is provisional coverage of complimentary therapies, holistic nursing etc.

Policies and Procedures: You may think that just because you are in private practice that policies are not necessary. It is always a good idea to have some basic written policies on subjects such as the type of clients you see, what services you offer, refund policies, under what circumstances you would discharge a client, etc. The advantage of written policies is that if someone challenges your decisions, you can show that you have guiding principles. You will also demonstrate that have taken the time to anticipate what may happen in your practice and are making decisions with equity.

Advertising Your Services: It is important that you use terms to describe what you do in a way that conforms to the definition of the general practice of nursing as well as of registered nursing. Use terms such as “health teaching, health counseling, care supportive to health and well being” rather than statements that you are providing therapy such as “complementary therapy.” The word “therapy” is a red flag that may cause your nursing colleagues as well as other health care professionals to question whether you are practicing beyond your scope of practice.

How you advertise yourself and the services you provide is crucial to maintaining your credibility as well as staying out of trouble with your licensing Board.

Mary Amdall-Thompson, RN, MS, CNS is a Clinical Nurse Specialist. She was employed by the Oregon State Board of Nursing for 21 years (until February 2003). During this time she answered scope of practice questions, drafted policy on scope of practice and supervised the investigation of complaints filed against licensees of the Board. You may contact Mary by E–mail at mamdall@attbi.com