International Journal of Nursing Practice

2003;

9

: 236–245

Blackwell Science, LtdOxford, UKIJNInternational Journal of Nursing Practice1322-71142003 Blackwell Science Asia Pty Ltd

94August 2003426

A Delphi study of nurse entrepreneursA Wilson

et al.

10.1046/j.1322-7114.2003.00426.xOriginal Article236245BEES SGML

Correspondence:Anne Wilson, Department of Clinical Nursing, The

University of Adelaide, Adelaide, SA 5005, Australia.

Email: anne.wilson2@adelaide.edu.au

✠

R E S E A R C H P A P E R

✠

The influences on and experiences of becoming

nurse entrepreneurs: A Delphi study

Anne Wilson RN RM BN MN GradDipHealthCouns CertPaed IWC PhD FRCNA

Research Fellow, Department of General Practice, The University of Adelaide, Adelaide, South Australia, Australia

Andrea Averis RN RM BSc MSc(PHC) PhD FRCNA FGLF

Coordinator, Primary Research, The Joanna Briggs Institute, Royal Adelaide Hospital, Adelaide, South Australia, Australia

Ken Walsh RPN RN PhD

Clinical Professor of Nursing, Waikato District Health Board and Victoria University of Wellington, Wellington, New Zealand

Accepted for publication November 2002

Wilson A, Averis A, Walsh K.

International Journal of Nursing Practice

2003;

9

: 236–245

The influences on and experiences of becoming nurse entrepreneurs: A Delphi study

There is little known about private practice nursing as an area of advanced practice. As more nurses take the option todevelop private practice, the experiences of and influences on nurses currently in private practice might be a useful guideto the pitfalls and difficulties which might be encountered. In addition, an understanding of the experiences of and influ-ences might assist nursing organizations and health services to provide support to nurses who play an integral part in healthcare delivery in the community. A research study was undertaken utilizing a two-round Delphi Technique to elicit andassess consensus on the reasons for nurses going into business and the experiences they encountered in becoming and beinga nurse entrepreneur. The study instrument in round one comprised a questionnaire with statement headings inviting opin-ions on the influences and experiences of nurses in business. In the second round, levels of agreement were elicited fromresponders on collated opinions from round one, including statements formed from comments written in round one. Theinitial questionnaire also included closed questions to obtain a profile of nurses in private practice. Responders were 59nurses in private practice in round one and 54 nurses in round two. The themes raised could be grouped under headingsof influences, advantages/disadvantages, education/experience, skills/knowledge, characteristics and barriers. The levelof agreement on the themes was reasonably high. Dissent occurred on issues of increased income, professional image andsupport structures. This Delphi study has identified key areas of consensus on the experiences of nurses in private practicewho have extended their career into the business arena. It has also identified areas in which further work needs to be car-ried out to understand this work of nurse entrepreneurs.

Key words:

business nurses, Delphi Technique, nurse entrepreneurs, private practice nursing, role development.

INTRODUCTION

The notion of nurse entrepreneurialism is not one that isusually discussed when considering the work of nurses.Nevertheless, changes in the Australian health system arehaving an impact on how and what types of health servicesare being delivered.

1

As a result, opportunities are appear-

A Delphi study of nurse entrepreneurs 237

ing for autonomous, independent nurses who choose towork directly with clients in a private practice setting.

2

Although not a new notion, as nurses operated their ownbusinesses as ‘private duty nurses’ from before 1900, pri-vate practice nursing in Australia has emerged morestrongly over the past 15 years with professional networksforming under the auspices of the Royal College of Nurs-ing Australia.

3,4

Self-employed nurse entrepreneurs whoearn some or all of their income from private practicenow establish businesses as clinical consultants, research-ers, educators and management consultants.

5

For the pur-pose of this article, a nurse entrepreneur is considered tobe a person who develops, organizes, manages andassumes the risks of a business, and is:

A proprietor of a business that offers nursing services of a direct care,

educational, research, administrative or consultative nature. The

self-employed nurse is directly accountable to the client, to whom, or

on behalf of whom, nursing services are provided.

6

Private practice provides an opportunity for experi-enced, well-qualified nurses to develop their expertise asconsultants in clinical practice, research, education andmanagement, and continue to contribute their specialistskills to the health sector. As such, they form a small butimportant part of the health care system and provide thepublic with a greater degree of choice regarding healthcare delivery.

An extensive search of the literature using Pub-Medical,Medline and Cinhal uncovered a wide range of journal arti-cles accounting for nurses’ reasons to undertake privatepractice and the experiences they encountered.

7–12

How-ever, only one research report that examined issues relatingto insurance, specialization, credentialling and accredit-ation for self-employed nurses in one Australian State,Victoria, was revealed.

13

This confirmed the importance ofusing the issues raised in the literature to form the initialDelphi statements for the pilot questionnaire. The signif-icance of this research study was to increase understandingof this field of nursing and afford greater insight into itsefforts to improve and maintain quality nursing serviceswithin the Australian health system.

This paper will describe the application of Delphi Tech-nique to explore private practice nurses’ perceptions ofthe influences regarding establishing and conducting abusiness and some of the experiences they encountered.These factors will be of interest for professional nursingdevelopment so that the profession can understand and

support its own as well as to assist the establishment ofpriorities to guide future nursing research.

A questionnaire utilizing Delphi Technique wasdesigned to elicit participants’ opinions pertaining to thecharacteristics, influences on, and experiences of privatepractice nurses in order to collect the initial data for theresearch. As discussed by various authors, the literaturewas used as an ‘expert panel’ to assist in the developmentof the statements for the first questionnaire which alsocollected socioeconomic data and information on the par-ticipants’ scope of practice.

14–18

Grounded Theory wasapplied to analyse additional concepts developed fromparticipants’ comments through two rounds of question-naires. The purpose of this article is to report on the out-come of the application of the Delphi Technique.

METHODS AND MATERIALS

Delphi Technique

The principles of the Delphi Technique were used to guidedata collection and analysis and used as a technique forincreasing agreement between participants on issuesunder investigation.

19

Delphi Technique was conceived as away to obtain the opinion of ‘experts’ without necessarilybringing them face-to-face. It has been found to be par-ticularly useful in business arenas and seeks to achieveconsensus through a three step process of thesis, antithesisand synthesis.

18

The method has been used to identify pri-orities and to achieve consensus.

19

As the researchers of anational study investigating nurses conducting a business,it was necessary to be sensitive to the subjects’ time lim-itations and availability to attend face-to-face meetings.Although a time-consuming method for the researcher asit calls for a multicycle administration of a questionnaire,the advantage for respondents is personal choice of timeand place to complete it. Although up to six rounds ofDelphi have been known, it is becoming frequently morecommon for two to three rounds to be the maximumapplication, depending on the individual study.

20

Feedbackfrom each round and iteration of selected items provideparticipants with the opportunity to modify their opinionon selected issues.

Delphi Technique is a postal questionnaire method util-izing open-ended questions or statements in order toobtain the ideas or attitudes of a number of people anon-ymously, without the necessity of organizing a meeting.

21

A form of judgmental analysis and group interview, it is anappropriate method for this research design for its value inextracting and combining the views of many ‘experts’ (the

238 A Wilson

et al.

sample), and providing a way of prioritizing issues forfuture directions.

22

The principle advantage of employingDelphi Technique in this national study was that it allowedaccess to a large number of opinions from a group widelyspread geographically without needing to try to bringthem together. The anonymity provided through its designhas the advantage of eliminating group influences whichcan occur in face-to-face group meetings and in reducinginfluences that might occur should the researcher beknown to the ‘experts’. In using Delphi Technique, theresearcher must be conscious of achieving adequate cov-erage so that all possible categories are uncovered, therebynot allowing the convenience of the method to prevent theapplication of a more suitable method.

20,23

Selection of panel members

Delphi Technique requires participants to be experts inthe field under investigation.

24

In this study, experts wereconsidered to be nurses in Australia who earned some orall of their income from self-employment. A purposivesample was sought on the grounds that only those nurseswith experienced knowledge of private practice nursingwere appropriate for the study.

25

Demographic data werecollected in round one to ensure this criterion was met.To ensure clarification on this point, participants werealso asked to indicate a yes/no response to the question‘Do you receive at least some of your income from beingself-employed in private practice (business)?’ A databasefor the group ‘Nurses and Midwives in Private PracticeAustralia’ was obtained from the Royal College of Nurs-ing, Australia. The group had formed from the combinedstate associations ‘Nurses in Private Practice, SouthAustralia’, ‘Nurses in Independent Practice, Victoria’ and‘Australian Visiting Nurse Association’ of New SouthWales. No other database for this cohort is known inAustralia. In addition, following a lack of response to twoadvertisements placed in two monthly nursing periodi-cals, a snowball-sampling approach was undertaken to

increase the sample from an invisible population.

26

Aninitial database of 106 nurses in private practice was com-piled for the study.

Questionnaires

Round one

The first round postal questionnaire asked respondents togive their views to several statements under two broadheadings, influencing factors and entrepreneurial qualities(Table 1). The statements were developed using informa-tion obtained from the literature search. The question-naire was piloted on 10 self-employed nurses acrossAustralia who were asked to suggest any additional topicsthey considered relevant to the survey. Revisions weremade in light of their responses and suggestions. The sur-vey package included a letter explaining the research, aninformation sheet and consent form for further particip-ation in the study. The nurses were asked to indicate theirlevel of agreement to the issues on a four-point scale(strongly agree, agree, disagree, strongly disagree). Afour-point scale was chosen to eliminate the bias of centraltendency found in a five-point scale.

25

The participantswere also asked to provide their opinion on the need forpostgraduate qualifications for developing, managing andrunning a private practice. Space was provided for respon-dents to add extra comments, information or issues thatthey considered to be relevant. In addition, participantswere asked to answer a set of closed questions regardingdemographic information.

Round two

Responses provided by participants in the first round wereanalysed with the Statistical Package for Social Sciences(SPSS)

27

, with which frequencies and descriptive statisticswere calculated. These rankings were summarized and fedback to participants for further ranking in a secondquestionnaire along with new items developed from

Table 1

Areas which affect the establishment and conduction of a private practice

Influencing factors Entrepreneurial qualities

Initial decision-making factors Qualifications required

Advantages of being in private practice Characteristics required to be a nurse entrepreneur

Disadvantages of being in private practice Skills or knowledge required

Barriers to conducting private practice –

A Delphi study of nurse entrepreneurs 239

comments written by the participants in the first round.Questionnaires were mailed to the 54 respondents fromround one, who were asked to rate their opinion of the 26statements. Once again, a four-point Likert scale fromstrongly agree to strongly disagree was used.

25

Followinground two, a report summarizing the results was preparedand distributed to respondents. Figure 1 shows the sum-mary flow diagram of two rounds and analysis.

RESULTS

Round one

A total of

n

=

106 questionnaires were posted to self-employed nurses in all states of Australia as indicated onthe database. Participants were sent a reminder notice bymail after two weeks. A response rate of 55.6% (

n

=

59)was achieved. Five respondents did not meet the eligibil-ity criteria resulting in a total sample of

n

=

54 study par-ticipants for round one (Fig. 2). As a universally agreedproportion does not exist for the Delphi Technique, and isdetermined by the researcher, based on resources, samplenumbers and aim of the research, the consensus level foragreement was predetermined at 51%.

24

When round one was completed, 16 significant factorswith a ranking of

≥

90% had been identified. It was inter-esting to note that the major influences on deciding toestablish private practice were a known need or a directrequest for the services being offered. Closely followingthese factors were the personal needs of the nurse in look-ing for a new challenge or because an anticipated need fortheir service existed.

The two advantages of being in private practice thatwere given the highest priority rating (100%) by partici-pants were having autonomy and being able to use indi-vidual skills and talents. All other items were rated highlyby participants (

≥

92.5%), with one exception (Fig. 3).Participants were almost equally divided in their opinionas to whether there was potential for increased income inthe future (49% agreement vs. 51% disagreement). Thisitem was resurveyed in round two. The participants’ratings of items under ‘disadvantages of being in privatepractice’ were more variable than in the other groupingsunder investigation. The most significant disadvantage,with an overall level of agreement of 76.9%, was consid-ered to be that of a reduced and variable income in privatepractice.

Analysis of opinions expressed by nurses on the barr-iers encountered in private practice (Fig. 4) showed strongagreement (96%) that the lack of reimbursement for feesfrom both public and private health insurance was a bar-rier. Other items that also rated highly were the perceivedlack of professional and collegial support for private

Figure 1.

Summary flow diagram of two rounds and dataanalysis.

Pilot (n=10)

Returned (n=7)

1st Questionnaire (n=106)

Returned (n=59) (55.6%)

Analysed returns (n=54)

Questionnaire 2 (n=54)

Returned (n=51)(94%)

Analysed (n=51)

Not returned (n=3)

Ineligible (n=5)

Not returned (n=3)

Not returned (n=47)

Figure 2.

Questionnaire 1 responses from each state (

n

=

54).

�

, Victoria;

�

, South Australia; , New South Wales; ,Tasmania; , Western Australia; , Queensland.

States

Num

ber

of r

etur

ns

20

10

0

240 A Wilson

et al.

practice and the attitudes of other health professionalstoward nurses in private practice.

There was strong agreement between participants on12 of the 13 items under the broad area ‘characteristicsrequired to be a nurse entrepreneur’ (Fig. 5). There was100% agreement on three items; namely that assertion,accountability and commitment are all personal and pro-fessional characteristics required to be an entrepreneur.Participants did not reach strong consensus on the item

‘desire to work alone’ (57.7% agreement). It was there-fore decided to resurvey participants’ opinions on thisitem in round two.

In the broad area ‘skills or knowledge required for pri-vate practice’, participants again reached high levels ofconsensus (

≥

92.6%), on all items with the exception ofone (Fig. 6). Participants were not convinced that therewas a need for previous business experience in establish-ing private practice with agreement rated at 34.6%. The

Figure 3.

Advantages in private practice.

�

, autonomy;

�

,flexible hours; , increased income; , increased worksatisfaction; , own boss; , able to use skills; , control ofdecision-making; , variety of functions; , making adifference; , quality care; , enhanced image.

Mea

n

2.6

2.4

2.2

2.0

1.8

1.6

1.4

1.2

1.0

Factors

Figure 4.

Barriers to private practice.

�

, acceptance of rolechange;

�

, lack of public knowledge; , lack of publicreimbursement; , lack of private reimbursement; , attitudesof other professsionals; , attitudes of other nurses; , lack ofindustrial support; , difficulties with referrals; , lack ofcollegial support.

Me

an

2.2

2.0

1.8

1.6

1.4

1.2

Barriers

Figure 5.

Characteristics of nurse entrepreneurs.

�

,motivation;

�

, flexibility; , ambition; , assertion; ,accountability; , commitment; , self-discipline; ,independent; , good listener; , desire to work alone; ,creative; , good imagination; , willing to take risks.

Mea

n

2.2

2.0

1.8

1.6

1.4

1.2

1.0

0.8

Characteristics

Figure 6.

Skills required in private practice.

�

, businessknow-how;

�

, management skills; , planning skills; ,multi-skilled; , customer service focus; , previous businessexperience.

Mea

n

2.6

2.4

2.2

2.0

1.8

1.6

1.4

1.2

1.0

Skills

A Delphi study of nurse entrepreneurs 241

need for a strong customer service focus was concededwith a unanimous 100% agreement rating.

Round two

All the respondents (

n

=

54) who participated in roundone were posted a questionnaire for round two. Aresponse rate of 94% was achieved (

n

=

51) (Fig. 7). Thequestionnaire contained 43 items which endeavoured toelicit consensus on the issues raised. Reasonably high con-sensus was evident with 16% of responses having 100%level of agreement, 65% of responses having overall levelsof agreement of

≥

80% and 93% of responses with overalllevels of agreement of

≥

51%. The levels of weakest agree-ment were seen in those factors that had, in the firstround, related to qualifications and support, as discussedlater. Participants wrote few comments and did not gen-erate any new information leading to the development ofnew categories. Consequently, this was considered anappropriate time to cease Delphi rounds.

24

Standard deviation was used to measure the stability ofconsensus and convergence of agreement between roundson items where opinion changed.

28

Table 2 presents quest-ions where opinion changed between rounds. The moderepresents the score most frequently chosen by the major-ity of respondents, the mean represents the group opinionof the participants, while the standard deviation, ‘as ameasure of spread, represents the amount of disagree-ment within the panel’.

28

The lower the level of standarddeviation, the higher the level of agreement within thepanel. Consistency in the mean between rounds demon-strates stability of opinion within the panel. The changes

demonstrated in the table show how the Delphi Techniqueworked between rounds and any change in conformitythat occurred in group opinion. Using standard deviationto measure the amount of agreement between roundsshows whether the consensus agreement occurred fromthe beginning or was due to the Delphi Technique process.Such information reassures the researcher of the qualityand reliability of the final decision and guides the conclu-sions that might be determined from the result.

The factors in which participants showed lowest agree-ment in their opinions related to the type of postgraduatequalifications and support infrastructure needed in privatepractice. There was strong agreement (92%) in support ofnurses holding qualifications in their particular area ofspeciality that was offered in their business. Only a third(31%) of participants considered a masters degree anecessity, whereas the majority of nurses (70%) sup-ported postgraduate diplomas or certificates, probablybecause this would support their practice. Business qual-ifications per se were not strongly supported (57%),although there was strong support (

≥

96%) for acquiringskills in planning, management and business issues.

The greatest levels of agreement between participantswere seen in those factors that were identified as activitiesor personal qualities needed to ensure successful and via-ble private practice. The nurses agreed unanimously thatnetworking, and being able to do this effectively, washighly desirable. Similarly, personal qualities of good self-esteem, perseverance and determination to succeed arerequired for successful enterprise.

DISCUSSION

The response rate for the study provided reliable infor-mation on the major factors confronting nurses in privatepractice. A reasonably consistent panel enhanced the rel-iability of the results. As Greatorex and Dexter assert,experts dropping out of a Delphi study between roundsmight end in the resultant consensus not being represen-tative of the panel, thus a drop-out rate of three nursesbetween rounds was acceptable.

28

The outcome of the study was that a number of impor-tant aspects regarding becoming a nurse in business andthe experiences of being a nurse in business were identi-fied along with additional information provided aboutthese aspects. The study explored the influences on nursesto establish private practice, the advantages and disadvant-ages of being in private practice, the barriers encounteredand the personal characteristics and skills required. It was

Figure 7.

Delphi 2 return rate.

52504840353020191330

Val

ue d

ays

post

-des

patc

h

40

30

20

10

0

Number of surveys

242 A Wilson

et al.

interesting that some participants commented that theadvantages of being self-employed outweighed thedisadvantages.

Influences

The study established that most nurses and midwives werenot in business because they were unemployable, unableto find work or because they were redundant or rede-ployed. Of importance to the study participants werework satisfaction, being able to use distinct skills and abil-ities, and being able to contribute to making a differencein health outcomes for individuals.

29

For some nurses,going into business had enabled them to return to nursingafter raising a family or suffering a back injury. For others,going into business was a better proposal than undertaking

a hospital-centred refresher course that was impracticablegiven their circumstances, or it was not their usual area ofwork or suitable for their changed circumstances.

The potential of increased income when the businesswas established was an attraction for many nursesalthough the current level of understanding and knowl-edge of nurse-run businesses is not at such a level as toensure rapid financial returns. Because of this, maintainingan income level when starting in business was essential formany participants. Although some nurses had the optionof continuing at a level of part-time employment, theyalso considered this hindered development of thebusiness.

30

Possessing experience in the product or service to beoffered was considered a prerequisite for business

Table 2

Change in consensus level between rounds

Question Agreement Mode Mean Standard

deviation

Result

Increased income is an advantage of

private practice

Round 1 51.0% 1 2.43 1.14

Round 2 58.0% 2 2.45 0.81 The panel was of reasonably stable opinion

across rounds but the amount of group

opinion increased. This is a classic Delphi

item.

16

A desire to work alone is a characteristic

of a nurse entrepreneur

Round 1 57.7% 3 2.10 0.87

Round 2

To be able to work alone is a necessary

prerequisite

98.0% 1 1.45 0.61 Increasing agreement with a large change in

group opinion, with questioning of the

trustworthiness of the final opinion. Another

round might not give a reliable result.

Increased professional recognition is an

advantage

Round 1 96.2% 1 1.52 0.58

Round 2 68.6% 2 2.12 0.82 Fairly stable group opinion but with variable

agreement.

The attitudes of other nurses are a barrier

Round 1 92.2% 1 1.55 0.76

Round 2 54.9% 3 2.31 0.86 Unstable group opinion with consistent

agreement with the consensus. This does not

give confidence in the decision or that a

repeat round would provide a stable opinion.

A Delphi study of nurse entrepreneurs 243

success, which meant being able to gather this experi-ence prior to establishing a business. Participants in thestudy admitted to an average of 21 years of experienceprior to going into business (Table 3). A network of othernurses in business or other individuals who could provideinformation, advice or support when required was con-sidered highly desirable when establishing a business. Topossess qualifications in the nurses’ areas of speciality wasconsidered more important than holding tertiary qualifi-cations. The qualifications needed depended upon thework undertaken with continuing education considerednecessary to maintain an individual’s knowledge and skilllevel.

31

Being in business

To achieve optimal success in this area of nursing, nursesin business need recognition from within both the pub-lic and private health systems, including recognitionfrom peak nursing bodies. Differences in opinion of thetype of supports needed were attributed to the differentdomains the participants worked in. For example, theneeds of educators and researchers were not the same.Collegiality was demonstrated by non-clinicians fre-quently stating their support for the clinicians to receiverecognition through the reimbursement of their feesfrom third party insurers. Reimbursement was consid-ered a major issue, signifying lack of acceptance and rec-ognition of nurses as independent providers of healthservices and an issue which the profession needs toaddress.

13

The most valued advantages of private practice nursingwere autonomy, increased personal and work flexibilityand the opportunity to make a contribution to providingquality care that could make a difference for health out-comes. The personal and entrepreneurial characteristicsconsidered essential for success in private practice weremotivation, flexibility, accountability, commitment, self-discipline, good imagination, creativity, willing to take arisk, an independent nature without necessarily wishingto work alone, perseverance, focus and vision. A customerservice focus with excellent planning skills was also con-sidered an important factor in business.

2

Limitations of the Delphi Technique

A Delphi Technique takes time, as asserted by Delbecq,Van de Van and Gustafson, who estimate the averageDelphi study takes 44.5 days.

32

Costs are incurred forsupplies, postage, printing and computer time. A poten-tial limitation of the Delphi Technique occurs if the teamor individuals who monitor the study have bias that dis-torts the results, exploits the privacy of the respondentsor imposes too restrictive a process on the participants,not allowing consensus to occur.

33

Delphi Techniquelacks the incentive of face-to-face communication whichmight result in participants or researchers feelingdetached, and create communication or interpretationdifficulties. In this study, one way of countering this wasto provide as much personal contact as possible; forexample personalizing letters and responding to personalcommunications. A quick turnaround time betweenquestionnaires was encouraged and aimed at reducingrespondent attrition by maintaining attention andmotivation.

Moreno-Casbas argues that lack of agreement regard-ing an adequate size of the panel in a Delphi study andthe lack of evidence that the results obtained might bereproducible also affects the validity of the study.

8

Con-tent validity is increased by the use of participants whohave knowledge and an interest in the topic. No com-mon agreement of what level of consensus is adequatehas been determined, so the level used is at the research-ers’ discretion and depends upon sample numbers, aimsof the research and responses. Consensus levels havebeen known to fluctuate between 51% and 80%.

24

Because this study is original research, the researcherestablished the meaning of consensus to be agreementamong at least 51% of the respondents. The attritionrate from the first round was attributed to the unknown

Table 3

Characteristics of the expert panel

Characteristics Analysis

Gender 98% female; 2% male

Average age 50.0 years

Average years of experience 21.0 years

Average length of time worked in

private practice

7.6 years

Majority of career worked in clinical

area

45.0% of participants

Majority of career worked in education 20.0% of participants

Majority of career worked in

consultancy area

33.3% of participants

Majority of career worked in research 1.7% of participants

244 A Wilson

et al.

accuracy of the database and the inclusion/exclusion cri-teria of participation in the study. Response bias wasreduced in the second Delphi round because of a highresponse rate (94%).

The lack of opportunity for participants to elaborateor discuss their viewpoint is a potential weakness of theDelphi Technique. This was overcome in this study byallowing participants to add comments to statements andprovide qualitative data which helped to increase thevalidity of the study. Concepts originating from the par-ticipants’ comments in round one were structured so as toprovide a means of debate or discussion in the subsequentround.

24

Overall, given the limitations of the Delphi Tech-nique, it was considered the most appropriate method togather the opinions of nurse entrepreneurs, to identifyinfluences on their decision-making and to highlight theissues specific to their work environment.

CONCLUSIONS

In conclusion, the high levels of agreement seen betweenthe participants on so many issues associated with privatepractice nursing indicates that there is consensus on whatis perceived to be important for this group of nurses.Equally important, however, are those few areas wherethe agreement levels are less strong. Further work needsto be carried out to tease out possible reasons for the dis-cordance, to ascertain why nurses hold different viewson the same topic. More importantly, studies that delveinto the outcomes associated with their work have muchto offer in increasing understanding of this area. It is evi-dent that private practice is a career option and might bechosen by those who wish to take advantage of opport-unities and/or to take on new challenges. There is ademand for nurses to market their skills as other healthcare professionals do and this has the potential of improv-ing the range of health services available. Providingnurses with the opportunity to be more entrepreneurialin nursing could lead to increased work satisfaction,development of nursing practice arenas and higher attrit-ion rates within the profession. If hospitals encouraged anincreased scope for advanced practice positions in spec-ialist areas then options for nurses could increase. A gapexists for nurse education curricula to address the educa-tion needs of planning, management and business issuesidentified in this study and for the profession to increaseits levels of support.

This study expands on the little that is known author-itatively about self-employed nurses, considers an innov-

ation that is developing nursing practice and illuminateswhat nurses know with an opportunity to tell others.

ACKNOWLEDGEMENTS

The researcher gratefully acknowledges the contributionof all the participants. This research study has been sup-ported by an Alfred and Ferres Scammel Medical ResearchScholarship awarded by the Faculty of Medicine, Divisionof Health Sciences, The University of Adelaide, SouthAustralia.

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