My Scope of Practice: The Challenges of a Nurse/Entrepreneur

   Theresa ("Terri") Maxwell, RN, MSN, FNP, CWOCN, has always worked two or three jobs at once. Not long after earning her BSN from Research College of Nursing/Rockhurst College, Kansas City, Mo., Terri worked simultaneously as a staff/ICU nurse and surgical unit nurse and served as a clinical instructor for the RN program at her hospital in St. Joseph, Mo.

She has been a nurse in a surgeon's office, a motivational instructor for high school students pursuing careers in health occupations, and a home health clinician. With her initial dream of starting her own business realized, she is now looking to make the most of her recent nurse practitioner certification and establish a full-service wound, ostomy, and continence clinic.

   While she was enticing students to consider health-related jobs, Terri worked full time as a home health care nurse. That didn't stop her from building up the part-time career-counseling program to full-time status. Because she was unable to teach full-time, she eventually left that program to do home health care exclusively, working as a region case manager for a home health company. Her interest in the wounds and ostomies she was seeing inspired her to pursue ET certification at M.D. Anderson, Houston, Tex., in 1999. "I had done ostomy care without certification for several years and found it rewarding. Plus, the ostomy nurse in the area passed away, which created a void. Although I knew filling her shoes would be difficult (she was such a wonderful person), I wanted to try."

   Because she didn't want to be hospital-owned, Terri went into business for herself, "sinking everything she had" into the endeavor. "My company - Image Specialties - is actually two businesses in one," she explains. "The retail store offers everything for the WOC patient, including durable medical equipment. As a certified mastectomy/compression specialist, I also carry compression and mastectomy-related products. I went into DME because I saw the way other companies handled patients, substituting where they shouldn't, overbilling, and subscribing to other (in my opinion) unscrupulous practices. I thought I could do better."

   The other half of the business involves contractual consultation to nursing homes, home health agencies, and hospitals. Terri says, "I deal with inpatients and outpatients, receiving self referrals and referrals from physicians. I provide pre-op teaching and site marking, inservices and educational programs, and I get patients involved in support groups that I have initiated and in which I participate. I also provide the supplies after surgery."

   To create better cash flow, she contracted with home health agencies to perform ET duties and insurance exams. After hearing about nurses involved in research, she put proposals to various vendors. She finds research one of the more rewarding aspects of diversification. "I get to test new products and stay up-to-date on the latest treatments," she says.

   A typical day for Terri involves getting into the office an hour before opening, seeing patients throughout the morning, and traveling to see nursing home patients in the afternoon. Three times a week or more, she sees hospital patients. Any "extra" time is spent assessing "stop-in's" in the office and seeing patients participating in her clinical studies. Occasionally, after-hours work is required either at the office or at home; Terri is available to her patients and customers by phone 24 hours/day. "Some days I may see 10 to 12 patients," Terri says. "It goes in spurts. As far as I know, I am one of only two ET nurses in the area, a basically rural locale in northwest Missouri, 50 miles north of Kansas City. I run hard from when I start until quitting time."

   Terri's hard work has been far from financially lucrative so far. "I wasn't getting paid," she says simply. "I couldn't bill Medicare and Medicaid because I lacked the credentials, although some insurance companies will pay an ET nurse for her services. People with Medicare were used to being served for 'nothing' and expected me not to bill. I see some of my patients who are also my customers out of courtesy, but those who purchase their supplies elsewhere are charged for my time and expertise. The largest health insurance in town handles 80% of the working public and they were willing to make me a provider…until they realized I wasn't a nurse practitioner."

   The solution? Back to school at the University of Missouri at Kansas City to earn her MSN as a family nurse practitioner. "I received a dual certification from the American Nurses Credentialing Center (ANCC) and the American Academy of Nurse Practitioners (AANP) in December 2001."

   Her recent certification will enable her to eventually realize her dream of expanding her business into a WOC clinic. Her patients are happy for her and say they can't wait. She presently has a storefront exam room and mastectomy room in St. Joseph and receives numerous referrals from outlying areas. "We're still small," Terri says. "My mom is my receptionist and insurance person - I couldn't have survived without her. A few months ago, I hired a part-time PT/RN for non-ET duties. I still handle pretty much everything else, including ordering, billing, and marketing." Terri is still diversifying because she enjoys home visits and doing research. She says she has several articles pending and is "open to all options."

   "I'm a pauper, but this is so rewarding," she says. "It always comes back to the individual patients. I see them before surgery and they are devastated. Seeing them when they return to normal life assures me that I've done my job well. For example, a 27-year-old man had undergone a colostomy and was having severe leakage problems. His sister practically dragged him in to see me. We were able to change his device and resolve the leakage until the surgery could be reversed. He told me I had made a huge difference in his life. That's important to me - to make a difference. I have earned the respect of my colleagues and patients and physicians tell me they are thrilled that I'm here. When my patients learned that I would be going back to school, they were concerned that I no longer would be available. I told them I am doing this to be more available. Nothing in nursing has been this hard or this rewarding."

   Meanwhile, life at home keeps her busy with her children as coach, former scout leader, and chauffeur. "Opening my own business allowed me to set my own hours. I try not to work weekends or holidays. My patients know this and try to plan ahead. But striking out on my own has been tough on my family. My hope is that once I am fully established, I will have more time with my husband and children."

   Terri thinks contractual nursing is a prime opportunity and the way of the future, but acknowledges that it isn't for everyone. "This has been a long, hard road - mentally, emotionally, and physically. You need the support of your family, commitment, and the right attitude. It would also be great to have the support of others who are in my shoes. Many times, you feel rather alone being an independent practitioner." Terri would like other nurses who run clinics to contact her; she attends conferences to seek their input and experience.

   Before she can get her clinic up and running, Terri needs her official number from Medicare and the support of a physician who would respect her independence and recognize her expertise as a practitioner. "I am determined to remain sole owner and CEO of my company." Until then, she is working part-time as a nurse practitioner and full-time in the office to add credibility for when she establishes the clinic. She also continues to conduct studies for nursing facilities and exams for insurance companies.

   "I've had offers of buy-out and to teach, but I am committed to my dream," Terri says. "Ultimately, I want to be able to support my patients before, during, and after ostomy surgery under the auspices of a one-stop wound and continence center. I want to include a clinic - maybe several - in my scope of practice."

   My Scope of Practice is made possible through the support of ConvaTec, A Bristol-Myers Squibb Company, Princeton, NJ.