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Revista Brasileira de Enfermagem

versão impressa ISSN 0034-7167versão On-line ISSN 1984-0446

Rev. Bras. Enferm. vol.72  supl.1 Brasília jan./fev. 2019

http://dx.doi.org/10.1590/0034-7167-2018-0498 

REVIEW

Entrepreneurship and Nursing: integrative review

Emprendedorismo de negocios y Enfermería: una revisión integrativa

Rosana Maria Barreto ColichiI 
http://orcid.org/0000-0002-8765-3965

Stella Godoy Silva e LimaI 
http://orcid.org/0000-0002-7468-6020

Andrea Bueno Benito BoniniI 
http://orcid.org/0000-0001-7185-3623

Silvana Andrea Molina LimaI 
http://orcid.org/0000-0001-9945-2928

IUniversidade Estadual Paulista Julio de Mesquita Filho. Botucatu, São Paulo, Brazil.

ABSTRACT

Objective:

To identify the knowledge produced on business entrepreneurship in Nursing.

Method:

Integrative literature review in the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, SCOPUS, Web of Science, PubMed, Medline, Latin American and Caribbean Literature in Health Sciences (LILACS), Nursing Database (BDENF), Index Psychology and National Information Center of Medical Sciences of Cuba (CUMED). We included available studies in their totality in the period from 2007 to 2017.

Results:

22 articles were included. The categories that emerged from the study are the following: Concepts of entrepreneurship in nursing, Profile of the entrepreneur nurse, Business Diversity, Business Management, Barriers to business entrepreneurship in nursing, Support to entrepreneurial nurses and Entrepreneurship in Nursing Undergraduate.

Conclusion:

There is a need to prepare nurses with adequate skills to increase the capacity to integrate into the labor market and to improve their own well-being and that of society.

Descriptors: Entrepreneurship; Job Market; Occupational Health; Nursing; Education, Nursing

RESUMEN

Objetivo:

Identificar el conocimiento producido sobre el emprendedorismo de negocios en la Enfermería.

Método:

Revisión de la literatura, realizada en las bases de datos: Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, SCOPUS, Web of Science, PubMed, Medline, Literatura Latinoamericana y del Caribe en Ciencias de la Salud (LILACS), Base de Datos en Enfermería (BDENF), Index Psicología y Centro Nacional de Información de Ciencias Médicas de Cuba (CUMED). Se incluyeron estudios disponibles completos, de 2007 a 2017.

Resultados:

Se incluyeron 22 artículos. Las categorías que surgieron en el estudio fueron: Conceptos de emprendedorismo en la Enfermería; El perfil del enfermero emprendedor; La diversidad de negocios; La gestión de Negocios; Barreras al emprendedorismo de negocios en Enfermería; Apoyo al enfermero emprendedor; y Emprendedor en la graduación en Enfermería.

Conclusión:

Hay una necesidad de preparar a los enfermeros con habilidades adecuadas para aumentar la capacidad de integración en los mercados de trabajo, mejorar su propio bienestar y el de la sociedad.

Descriptores: Contrato de Riesgo; Mercado de Trabajo; Ocupaciones de Salud; Enfermería; Educación en Enfermería

INTRODUCTION

Although the study on entrepreneurship has been intensified since the 1970s, there is still no single concept defined in relation to the subject. However, for some authors, entrepreneurship consists of a set of practices adopted with the purpose of guaranteeing the generation of wealth and the better performance of societies(1).

Thus, the literature has presented us with several ways of interpreting the theme, such as: intrapreneurship in the organizational sphere, generally related to leadership and the vision of quality improvement in work environments; social entrepreneurship, in which changes are promoted in a group of people in society; and business entrepreneurship, with the opening and management of enterprises, the latter being the focus of this study(2).

Through business entrepreneurship, young people can increase their capacity to integrate into the labor market, accumulate skills and improve their own well-being and that of society. At the same time, fostering this form of entrepreneurship is fundamental to innovation and can serve as an engine for the necessary transformation of production and contribute positively to incomes, driving inclusive economic growth(3).

Investing in skills and entrepreneurship also means tapping current and future trends in these areas and providing opportunities for social, political and economic transformation. Investing in skills can also improve the transition of young people from school to work(3).

On the other hand, there is currently a setting in Brazil of intensive commodification of the health sector and transfer of public funds to the private sector(4), which has given new directions to the nurses' labor market. be taken into account by future professionals.

Indirect contracting, which uses models of management contracts through Social Health Organizations (OSS - Organizações Sociais de Saúde) is a phenomenon that has been occupying space in the Brazilian Public Administration. The adoption of this tool has been associated with: the limits on the hiring of public servants imposed by the Lei de Responsabilidade Fiscal (Law of Fiscal Responsibility) the flexibility of human resources management and the improvement of management (planning, assessment or rendering of accounts)(5). However, the linkage of the remuneration of health professionals to performance indicators, in spite of being one more device to improve the quality in the health services, in practice, can result in lower remuneration to the nurse contracted by OSS.

The possibility of outsourcing health services is observed with the Ministry of Health's standardization of private participation in the execution of health services and the accreditation of health service providers in the Brazilian Unified Health System – SUS- Sistema Único de Saúde (subsection XIV of art. 16 of Law 8080/90). The contracting of services of the private institutions in a complementary way allows supplying the insufficiency of the services in the public sector. Given the peculiarities of health services within SUS, where demand is usually higher than supply, this situation can be understood as a promising market for business entrepreneurs.

The current social dynamics - such as the constant increase in life expectancy, the expansion of women's work in the labor market, new family arrangements and new lifestyles - has also been working in the opening of new fields of professional nursing work(6).

Allied to the globalization of the economy and the technological advances, this new setting indicates ways still little explored by the nursing professional.

The current Diretrizes Curriculares Nacionais (freely translated as National Curriculum Guidelines) of Nursing undergraduate course establish as one of the skills of the nurse the administration and management, and the professionals should be able to be entrepreneurs, managers, employers or leaders in the health team(7).

Recently, the Resolution of the Federal Nursing Council (COFEN - Conselho Federal de Enfermagem) 568/18, which regulates the operation of nursing clinics and offices, has been recently published, valuing the nurse's entrepreneurial character by recognizing the legal personality of these services.

In order to contribute to reducing the gap between nursing education and labor market requirements, it becomes necessary to investigate entrepreneurship in this profession in a comprehensive way. And, to better understand the theme, it is important to know how the production of knowledge in national and international journals on business entrepreneurship in Nursing is configured, in order to provide subsidies to teachers and nursing researchers.

OBJECTIVE

To identify the knowledge produced on business entrepreneurship in Nursing.

METHOD

This is an integrative review of the literature with expanded analysis of the literature, allowing discussions on methods and research results, as well as reflections on future studies(8). The integrative review is still defined as a tool for access, identification, analysis and synthesis of the literature of a given theme, allowing a broad view of the subject, the methods used and the results of publications(9). With this method it is possible to synthesize and produce conclusions about the knowledge produced by studies about a certain phenomenon, using a guiding question in the search of this literature(10).

In order to perform an integrative review, it is necessary to: define the problem by means of the object of the review presented as a question or primary hypothesis; sample selection after defined inclusion criteria; the characterization of the studies (the characteristics or information to be collected are defined by clear criteria, guided by a tool); analysis of results (identifying similarities and conflicts); and the presentation and discussion of the findings(9).

Starting from the definition of the problem, the guiding question of the revision was: how does the production of knowledge about business entrepreneurship in Nursing?

The selection of the sample was established for a period of 5 years prior to September 2017 for online access to the health databases available at the Capes (www.capes.gov.br) and Bireme - Virtual Health Library (VHL). In the Capes portal, the following databases were consulted: CINAHL (Cumulative Index to Nursing and Allied Health Literature), EMBASE, SCOPUS, Web of Science and PubMed. In the Bireme portal - Virtual Health Library (VHL), the research resulted in articles from databases such as Medline, LILACS, BDENF-Nursing, Index Psychology - technical-scientific journals and CUMED.

In order to ensure a broad search of primary studies, the controlled descriptors (search terms) were combined in different ways, using Boolean operators OR and AND: Descriptors in Health Science (DeCs) to elaborate search strategy in the BIREME portal; in Medical Subject Headings (MeSH) for the SCOPUS, Web of Science and PubMed databases; in Emtree for elaboration of search strategy in Embase.

Due to the inconsistency of the results presented in the VHL, four different search strategies were used to better delineate the research, with additional descriptors, generating different sample numbers. The sum of these searches and the respective selection of articles were used. In the search for a representative sample number, the time period was expanded to 10 years for the SCOPUS, PubMed, CINAHL, Web of Science and EMBASE databases.

For these surveys, librarians assisted in the elaboration of the search strategy and in the bibliographic survey.

For the systematization of data, a collection tool was developed with the data related to authors and publications, verifying the relationship between Nursing and business entrepreneurship.

The inclusion criteria were: articles available related to the research object, in Portuguese, English or Spanish, originated from national and international journals, indexed in the databases mentioned up to September 2017. The following exclusion criteria were adopted: tool validation, intrapreneurship (skills) and social entrepreneurship. A total of 4,731 articles were found in the databases, of which 22 were established as analysis bodies, according to the flowchart of Figure 1.

Figure 1 Study selection flowchart, 2017 

RESULTS

The scarcity of studies on the subject has been confirmed. Among the 22 articles selected, 5 (23%) were published in 2013, three (14%) in the years 2015 and 2016, two (9%), in 2007-2009, 2012 and 2014, and one (4%), in 2011. A higher prevalence in the last 5 years (2012 to 2016) is observed, with more than two-thirds of the sample body.

The selected articles cover the world setting, but the United States (7/32,0%), followed by Canada (3/13,6%) and the United Kingdom (3/13, 6%). Australia, Brazil and Iran had two (9.1%) studies each. Other studies were conducted in Finland (1/4.5%), Spain (1/4.5%), and Tanzania, Kenya and the Philippines (1/4.5%). It should be noted that the three articles whose studies were carried out in Canada refer to the same research.

The prevalence of qualitative research (6/27%) and theoretical model studies (6/27%), followed by quantitative (5/22%), three (13%) revisions and two (9%) case studies. However, three articles classified as qualitative research refer to the same study performed with a focus group.

Although the theme is comprehensive and multidisciplinary, most of the articles were published in specialized journals in Nursing (14/64%). In the other journals, health journals had the following scope: safety and work (3/13.5%), management (1/4.5%), technology (1/4.5%) and public health/4.5%). Only one (4.5%) was related to gender and work, and another (4.5%) specialized in small business and entrepreneurship, reflecting the low impact of Nursing in business areas.

The work made it possible to identify the knowledge produced in the literature in national and international journals about business entrepreneurship in Nursing.

The scarcity of studies on the subject has been confirmed and is still reflected in the occurrence of few studies considered experimental and quantitative. For this reason, we also observed the prevalence of qualitative research and case studies, since the methodological strategies adopted in these studies in a restricted environment allow an expanded understanding of the phenomena studied and may also require multidisciplinary approaches and the combination of different forms of research methodologies(11).

Among the reviewed studies, shown in Chart 1, after extensive reading of the full texts, we found research that seeks to assess and interpret business entrepreneurship in Nursing in several aspects. From the analysis and from the perspectives outlined by the authors, the following themes emerged: a) Concepts of Entrepreneurship in Nursing, b) Profile of the Entrepreneur Nurse, c) Business Diversity, d) Business Management, e) Barriers to Business Entrepreneurship in Nursing, f) Support to the Entrepreneur Nurse; and g) Teaching of Entrepreneurship in the Undergraduate Education in Nursing.

Chart 1 Characterization of articles selected for analysis according to order, title, author, year, objective of the study, 2017 

Seq. Article/authors/year Objective of the Study
2 Rising to the challenge of health care reform with entrepreneurial and intrapreneurial nursing initiatives (Wilson, Whitaker & Whitford, 2012)(2) To provide a global perspective on the evolution of nursing functions to innovation in health care. A historical view of entrepreneurship and intrapreneurship is offered. It also includes the discussion of a social entrepreneurship approach for Nursing, configurations for intrapreneur nurses and implications for research and practice.
6 Barriers to nurse entrepreneurship: a study of the process model of entrepreneurship (Elango, Hunter & Winchell, 2007)(6). To collect information from nursing professionals through focus groups on the barriers to starting a business.
12 Iranian entrepreneur nurses' perceived barriers to entrepreneurship: A qualitative study (Jahani, Abedi, Elahi & Masoud , 2016)(12) To describe the barriers perceived by Iranian entrepreneur nurses to entrepreneurship.
13 Entrepreneurial nurses and midwives in the United Kingdom: an integrative review (Drennan et al, 2007)(13) To investigate: the extent of business activity by nurses, midwives and health visitors in the United Kingdom and (b) the factors that influenced these activities.
14 An investigation of the international literature on nurse practitioner private practice models (Currie, Chiarella & Buckley, 2013)(14) To investigate and synthesize international literature around private nurse practice (NP) models to provide an exposition of common points and differences.
15 Nursing entrepreneurship: motivators, strategies and possibilities for professional advancement and health system change (Wall, 2013)(15) To explore the experiences of autonomous nurses, who see themselves as leaders in the advancement of the nursing profession, and their contribution to health care.
16 When the business of nursing was the nursing business: the private duty registry system, 1900-1940 (Whelan, 2012)(16) To describe the labor market origins of private law nurses as the primary field of employment for early nurses and ways in which the private law registry system has connected nurses and patients in the US.
17 Education for entrepreneurship in nursing (Boore & Porter, 2011)(17) To present a strategy for the development of entrepreneurship education in a region of the United Kingdom and its integration into a pre-registration nursing program (NICENT)
18 Nurse entrepreneurs' attitudes to management, their adoption of the manager's role and managerial assertiveness (Sankelo & Akerblad, 2008)(18) To explore the attitudes of Finnish nurses entrepreneurs for management, adopting the manager's role, managerial leadership skills, development and management training needs and associated factors.
19 Do nursing students have entrepreuner profile? (Roncon & Munhoz, 2009)(19) To know the profile of the undergraduate students of an undergraduate nursing course on entrepreneurship.
20 Consulting in occupational health nursing (Roy, 2013)(20) To provide an overview of the consulting practice, process, roles, and roles of Occupational Health nursing consultants and present some common characteristics of successful consultants.
21 Entrepreneurship in Nursing: overview of companies in the State of São Paulo (Andrade, Dal Ben & Sanna, 2015)(21) To identify and characterize the nursing companies run by registered nurses registered in the Commercial Board of the State of São Paulo until 2011.
22 Self-employed nurses as change agents in healthcare: strategies, consequences, and possibilities (Wall, 2014)(22) To investigate how independent professionals perceive the contemporary health field, what attributes they have that facilitate their roles as agents of change, what strategies they use to influence change and what consequences they face in their actions, thus contributing to that is known about organizational change in institutionalized contexts, such as health.
23 Dimensions of precariousness in an emerging sector of self-employment: A study of self-employed nurses (Wall, 2015)(23) To examine the experiences of independent nurses in order to better understand self-employment in occupational care work from the point of view of precariousness.
24 Embedding nursing and therapy consultantship: the case of stroke consultants (Burton, Bennett & Gibbon, 2009)(24) To explore the factors that shape how consultants have been incorporated into stroke services in the UK while opportunities for experienced professionals to advance their careers in clinical practice.
25 Providing Healthcare Services at Home-A Necessity in Iran: A Narrative Review (Nikbakht-Nasrabadi & Shabany-Hamedan, 2016)(25) To investigate a comprehensive system to provide the provision of home health care in Iran.
26 Advancing nursing enterprises: A cross-country comparison (Pittman & Salmon, 2016)(26) To explore cases of nursing companies in the developing world and discuss their potential to report related work in the United States.
27 What are consulting services worth?: applying cost analysis techniques to evaluate effectiveness (Mastroianni & Machles, 2013)(27) To report how occupational health nursing consultants, whether internal or external to the organization, should document the benefit and effectiveness of the services provided.
28 Ten common mistakes to avoid as an independent consultant: an update (Hau, 2013)(28) To describe errors in assumptions and business practices that limit the success of a nursing consultant and ways to avoid them.
29 From unmet clinical need to entrepreneurship: taking your informatics solution to market (Bowles & Heil, 2014)(29) To describe the process for taking a decision-making solution in the market as a business by sharing the steps of answering a clinical question, registering an invention, creating a business and business plan, securing venture funding, and launching a commercial product.
30 Patient satisfaction with retail health clinic care (Hunter et al, 2009)(30) To analyze patient satisfaction with care provided at two retail clinics by family nursing professionals (FNPs) and physician assistants (PAs).
31 Social cognitive determinants of entrepreneurial career choice in university students (Lanero, Vázquez & Aza, 2015)(31) To test a business career choice model in college students based on the Cognitive Social Career Theory, verifying whether business interests affect career choice and whether perceived self-efficacy is related to expectations of outcomes and whether both constructs affect interests and choice career.

The themes that emerged from the present study were grouped into six thematic axes according to the analysis and perspectives of the researchers, namely: a) Concepts of Entrepreneurship in Nursing, b) Being an Entrepreneur Nurse, c) Business Diversity, d) Business Management, e) Barriers to Business Entrepreneurship in Nursing, f) Support to the Entrepreneur Nurse; and g) Teaching of Entrepreneurship in the Undergraduate Education in Nursing.

The Concepts of Entrepreneurship in Nursing describe and discuss the types of entrepreneurship observed in the area of Nursing, comprehensively addressing the subject, its dimensions and domains of the entrepreneur's professional life. There is convergence in the characterization of three ways of undertaking in Nursing, according to the performance of the professional: the business entrepreneur, the intrapreneur and the social entrepreneur.

In the Profile of the Entrepreneur Nurse, the characteristics, attitudes or personal competences were grouped, as well as the reasons and opportunities that impel the nurse to undertake.

Regarding Business Diversity, the different possible market niches for entrepreneurial nurses can be observed in most studies, by specifying the business area of the participants in the experimental studies, in the case reports described in review or exemplifications, and in the citations in theoretical works. It is observed that the business sector is influenced by many factors, such as location, economy, legislation and culture where it is established, in addition to those related to the skills of each entrepreneur.

The Business Management theme covers the assessment of ventures, errors and management guidelines.

Barriers to Business Entrepreneurship in Nursing cover the obstacles faced by practitioners who have been the subject of direct research in at least five studies. The other works reinforce these barriers.

Grouped in the axis Support to the Entrepreneur Nurse, the various forms of assistance to the professional of nursing to become an entrepreneur are presented.

Regarding the Teaching of Entrepreneurship in Nursing, this one is incipient, bitter in traditional models and still needs more attention.

DISCUSSION

Business entrepreneurship offers nurses opportunities for self-employment using innovative approaches. Similar to other entrepreneurs, the nursing professional can be a business owner, offering clinical practice nursing services directly, education, research, administrative or even consulting. Directly accountable to the client, can act through a private or public individual organization. By using creativity, you can develop a new idea, improve service or delivery methods, or develop new products or new ways to use existing products. By combining personal characteristics with advanced or specialized skills and knowledge, business nurses can create products or services and market them to external sources(2,12-13). Here we also include professionals dedicated to private practice, self-employed or business owners(14-16). This concept would also be related to the risks inherent in business and profits(17). It is worth mentioning that entrepreneurial nurses already exist since the beginning of the last century in the form of self-employment, when nurses were independent, worked and received payment directly from private patients who needed nursing services(16).

In contrast to the entrepreneur, an intrapreneur nurse is a salaried employee, often a government-run health service, who develops, promotes, and offers an innovative health or nursing service within a health setting such as hospitals and clinics. Nurses have been developing intrapreneurship ventures since the time of Florence Nightingale; However, only now, with the growing demand for safe, high-quality and effective health services, more resources are being devoted to nurses assuming a wider range of roles, with more responsibility(2).

Social entrepreneurship is an approach that involves the conception and implementation of innovative ideas in which the nurse seeks practical models to promote social and environmental goals. Although business is commonly seen as a business venture for financial gain, in nursing, entrepreneurship can be seen as a way to get good health outcomes for the greatest number of people. As such, these initiatives represent examples of nurses who do well for society at large. Generally associated with volunteering and non-profit institutions, such design does not necessarily exclude profit, and can foster entrepreneurs and increase opportunities within the profession(2).

However, in all situations, professionals must be clear that a business entrepreneur nurse, intrapreneur or social entrepreneur should always do more with less. Nurses, in any area of practice or level of activity, contribute in a valuable way to health care by demonstrating the characteristics and abilities of entrepreneurship(17), also responding to the social and economic development of their organizations and countries.

Business nurses have more individually oriented profiles than the rest of the population and take a positive attitude toward business management(18). Individual responsibility and effort are distinctive features of nurse entrepreneurs, who are also leaders by nature. They are autonomous and wish to achieve and create for their own sake; want to be seen as superior to others and succeed. Nursing entrepreneurs are risk takers, are more innovative than non-entrepreneurs and have a strong control space; in other words, they believe that they can influence outcomes by ability, effort, and ability(18). The entrepreneur still has the need to accomplish new things, to put into practice his own ideas(12,19). Ability to communicate and focus on the practical solution of problems, besides initiative are other characteristics inherent to the entrepreneurs(20). Knowing how to recognize opportunities seems to be an important factor(6), but knowing how to exploit them becomes essential(21).

Certain characteristics of an entrepreneur are recognized as those inherent to a good nursing professional, since they must be creative, innovative, confident, motivated, realistic, work hard and have good communication(17). In this sense, nurses find ways to make, see, feel, communicate and learn to improve the quality of care directly with patients or, indirectly, through management, education, research or policy(17).

Among the external reasons that lead a nursing professional to private practice or business opening, not opting for institutional employment with traditional nursing practice arrangements in hospitals and clinics, are the negative views in these organizational environments, which were subject to changes in the health system of the countries(13,15,18). The following are reported: care gaps, shifts, dysfunctional stressful environment, work overload, disease-oriented care, medico-centered model and hospital care model(15). The lack of autonomy and influence on work, in addition to low salaries are also described(18).

Health systems that enable greater diversity in health service providers can create opportunities for nurses to act in an entrepreneurial way, as has occurred in the United Kingdom and Finland through legislative and policy changes, particularly in primary medical services(13,18). In Brazil, the adopted model is SUS, based on principles such as the universality of care. In an unstable and still developing economy, the Brazilian population tends at first to seek free health services. However, the reduced supply of public services compared to high demand has contributed to the search for other health services available in the private sector, creating new entrepreneurial markets.

Viewed as opportunities, some factors that encourage entrepreneurship in Nursing include: demographic trends such as population aging, generations willing to pay for health, lack of time and children acknowledging that they cannot care; opportunities in health facilities due to lack of labor, temporary services, cost reduction, outsourcing and the insertion of supplementary services not covered by public services or health plans; and social trends related to lifestyle, convenience, preventive health, and hospital closure(6). Nursing is seen here as a differential in some businesses due to their technical knowledge and personal care skills, expanding their roles and opening new paths(15).

The internal motivation is diverse. Many of the nurses surveyed feel limited and want to make a difference for patients and their families, need to follow their own goals, values, go beyond medications and procedures, put their knowledge and skills into practice(15). Many want to be their own boss; have greater autonomy; be able to practice in a better way; have career control; to be in charge; take risks; finally, to be successful(18). There is also the attraction for more flexible work schedules, in order to generate income in a way that fits with other family responsibilities(13).

The diversity of business is highlighted, since possibilities are presented in primary, secondary and tertiary care for the performance of the entrepreneur nurse. However, in business entrepreneurship there is prevalence in primary care(2,13).

The predominance of health-related businesses was observed, with nursing activities being reported, mainly private practice, in addition to services such as home care(2,12,14-16,21-26); wound care is also described(12,15,22-23); with diabetics(15,22-23), stomas(13) and stroke(24).

There are reports of expansion of the area of action beyond health, assuming non-traditional roles, acting in fields such as aesthetics, podiatry and alternative treatments. This valuation has been related to the knowledge inherent to the nurse, which brings an additional value in the provision of these services(15,22-23).

Consulting, consulting and project management services are on the rise, as professionals in this area become responsible for presenting solutions to complex problems and creating changes(2,13,15,20-24,26-28). Among the articles studied, the consultancies in the area of Occupational Health had relevance, being seen as strategic, since they can prevent problems, improve the well-being of the workers, control the costs with health care and absenteeism, as well as the retention of talent in companies(20,27).

Other niches are also cited: equipment rental(21); training(21,24,27-28); Occupational Health(15,20,22-23,27-28); education(2,12,15,21-24); trade and marketing of products(6,12,21); technology (software development)(29); private clinics(2,30); nursing homes(2,25); transport of patients(2,12); alternative therapies(12,15,22-23); podology(15,22-23); aesthetics, such as laser hair removal(15,22-23) and application of facial cosmetics(13); care of children and adolescents(18); research(2,24,); invention and manufacture of products(13); and investment fund for nurses(12).

The study by Drennan et al. (2007) classifies the possible activities for the entrepreneur in nursing in indirect and direct. The services would be rendered in an indirect way in the cases of consultancies, suppliers of infrastructure and labor force and inventors / manufacturers; the direct health services delivered by the national health systems, direct visit services to clients, other health-related services provided directly to a client, accommodation with nursing services and other health-related services(13).

In addition to this range of activities, attention should be paid to the existence of under-registration, since many of the professionals act as entrepreneurs in private practice without, however, formalizing or notifying the opening of a company. Under-registration is reinforced by the lack of legislation allowing such registration, which occurs in several countries.

The assessment of enterprises managed by nurses reveals the nurse as a business manager. A fact confirmed by the scarcity of literature, it was found that, despite being an expanding activity, the number of companies opened by nurses and private practice is reduced(13,21,26). Most entrepreneurial nurses are providers of direct nursing services (private practice) and are owners of small businesses and small enterprises(15,21), with low investments(21-22).

Studies give management guidelines and present the new role of the nurse, now as a manager. In addition to describing consulting services(20,24,27-28), there is clarification on how to plan, seek information, analyze costs and better communicate with clients(27). In addition, the importance of working networks with the community is also reported because of its importance in the dissemination of its services(6).

Business nurses have the ability to take a positive attitude toward management, but there are obvious shortcomings in adopting the manager's role and managerial assertiveness. Most of them present management development and training needs(18). In other words, there is evidence that nurses who are planning to start their business must have a previous leadership experience and must participate in some form of management training(18).

Studies describe errors in assumptions and business practices that limit success, revealing the nurse's lack of preparation to assume the role of entrepreneur in conducting his or her business. Among the most common problems are: choosing unprofitable markets, underestimating the time needed to properly provide services, non-existent or inadequate business plans, undervalued prices or incorrect services. Even with a large customer base, poor cash flow management, inadequate legal precautions and lack of contingency planning are critical concerns. The pros and cons of various forms of business are explored, such as partnerships, enhancing proper understanding of pitfalls and ways to avoid pitfalls(28).

These errors can be minimized by forming a good management team in cases of greater complexity. Defining roles and people with the right profile seems to be an essential ingredient for a successful business(29).

Allied to a good business plan, creativity and innovation in the opening of businesses can bring important results to the nurse entrepreneur, as the case of nursing clinics inside large shopping centers, being presented as an option to expose the profession due to good visibility, convenience of location, unnecessary scheduling, short wait times and low prices(30).

In the context of entrepreneurship in nursing, another important strategy is bootstrapping. In this concept, it is implicit to find ways to support a business until it becomes profitable, without harming patient care. Clinical equipment along with other business equipment can be bootstrapped for a nominal cost. You can use the following logic: do not buy new what you can buy used; not buy used what you can lease; do not rent what you can borrow; not to borrow what can be changed; do not change what you can ask for; do not ask what you can do without(6).

The main Barriers to Business Entrepreneurship in Nursing identified in this study are presented below:

  1. Legal and regulatory issues - There is a lack of knowledge of legal issues, reimbursement policies and procedures for the collection of hospitals, health plan operators, states or insurance companies(6,15,22-23). In this same sense, the complexity of bureaucratic processes for registering or licensing private businesses and waiting too long(12,26).

  2. Regulation of the profession - Reflecting a traditional nursing structure, in most countries private practice is unregulated, with a limited scope of nursing practice and, in many cases, still depending on the authority of physicians(12,14,25-26).

  3. Job career culture - there is a tendency to pursue careers in public health institutions, especially in countries where the state is largely responsible for health and privatizations are less present. In countries with unstable economies or times of recession, families and citizens tend to look for lower risk sources of income, even if the financial reward is lower, because they generate greater security, especially for employees in government institutions(12).

  4. Social values - Often, by local culture or religious issues, families can be in charge of caring for people. This model reduces the chances of hiring nursing professionals for this care(25).

  5. Medical-centered model - In this organizational format, the main duty is to obey and follow the orders of physicians and, under such conditions, it becomes difficult to play care roles that would be, at least theoretically, the responsibility of nurses. In some countries, this submission is reinforced by local culture, where the role of public policy manager is performed exclusively by physicians(12).

  6. Hospital care model - in this standard, access to therapeutic tools for primary, secondary and tertiary prevention is centralized in the hospital activity, with the private area remaining the focus in primary care and in the prevention of diseases(14).

  7. Reimbursement for health systems: The method adopted in some countries, both public and private, does not provide for any form of payment, establishes a lower value payment, or even conceives coverage of services by health plans inadequately(12-14,25).

  8. Collaborative arrangements with physicians - the collaborative arrangement is understood as the partnership between a nurse and a physician working in a private practice, being a model required in some countries as a reimbursement criterion. In this model, besides the difficulty of finding a physician with whom to collaborate, the latter may charge a fee for the establishment of the collaborative arrangement. In addition, these relationships reinforce the medico-centered model(14).

  9. Economic crises and recessions: economic stability brings predictability and there is a tendency for entrepreneurs to invest in new business, innovation and technology. However, financial crises and periods of long recession generate insecurity and reduction in new investments(20).

  10. Lack of preparation for the role of manager and lack of operational skills, resulting in the need for managerial development and training due to his deficiencies in business management. Many report, even, the ignorance of how to make a business plan(6,12,15,18,22-23,27).

  11. Personal and ethical conflicts: personal values prevent the opening of businesses related to caring for people, since profit generates ethical conflict; make money would be incompatible with the mentality of nursing services, more related to volunteering than to profit(6,12).

  12. Lack of acceptability and recognition by the public and by the class itself(14-15,22-23,25,30), still represented by jealousy and the joke of their colleagues. Behaviors such as these, presented by peers, can unfortunately have adverse psychological effects on entrepreneurs. The same feeling is noticed when colleagues do not accept, do not help or even hinder the disclosure of the business(12).

  13. Lack of corporatism among nurses. This tendency is not observed to privilege the interests of the professional group itself, reflecting more individualistic and less supportive attitudes(12).

  14. Lack of public policies(6). Also expressed in the form of incentives for private practice or the opening of new businesses for which no discounts, exemptions from fees or other practices are granted(12,25).

  15. Lack of technical support, since nurses are accustomed to the hospital environment and teamwork(6).

  16. Non-change culture. Many health managers do not believe in change, they walk conservatism. This is reinforced when there is great turnover in replacing these administrators(12).

  17. Unfair competition: Many services, mainly home care services, are provided by undergraduate professionals - often illegally, since they are not supervised - who practice lower prices and with questionable quality of services(12,25).

  18. Gender issues: understood in many cultures as a masculine quality, entrepreneurship in an almost massively female profession has taken some time to be understood as a form of empowering women and bringing benefits to the whole community(15,22-23,26).

Despite all these obstacles, there are reports of several ways to help the nursing professional to become an entrepreneur.

There is a record of organizations supporting private practice nurses in the US as early as the early 1900s, which were a link between patients and nurses of the time, impacting the management of these services with registration, training, operation and administration of this business(16).

Among the suggestions from organizations in which the nurse entrepreneur can seek resources, there are indications in the US of the Small Business Development Centers (SBDC) and the Service Corps of Retired Executives (SCORE)(6). Similar Brazilian Service of Support to Micro and Small Companies (SEBRAE - Serviço Brasileiro de Apoio às Micro e Pequenas Empresas), the SBDC provide services through professional business consultants. On the other hand, SCORE is a network of specialized business volunteers and mentors.

Professional associations(6,22) and Cooperatives(6) can offer various forms of support, from technical to managerial. Examples are the Private Nurses and Midwives Association Tanzania (PRINMAT), a social franchise in Kenya (Tunza) and a cooperative in the Philippines (EntrepreNurse). All enable nurses to lead and promote their professional influence. With the social mission of improving access to the care of disadvantaged populations, they still make it possible to increase employment and empower women. They also provide a shared platform for branding, purchasing, and quality assurance. Each one demonstrates the importance of a collective approach to the advancement of nursing companies. For PRINMAT, the main interest is to promote the profession, while the social franchise of Tunza has, as a main interest, the expansion of services aligned with the focus of the NGO franchiser in family planning. PRINMAT is a member association that offers training, loans, clinical standards and advocacy, while Tunza is a social franchise that offers, in addition to common marketing techniques and branding strategies, additional subsidies and a more rigorous quality assurance system. In the case of the EntrepreNurse cooperative, although the government has initiated and funded it, the bottom-up approach allows each group of nurses to define services based on their own interests and the perceived needs of the community. In this sense, a cooperative approach can be useful when job creation is the priority, although the model of association may be more applicable to situations in which nurses and midwives already have established independent practice and are well-regarded in the community. A social franchise approach, in turn, may be more applicable when public health experts have identified an area of severe need, both in terms of access and quality(26).

Health facilities, ie health care facilities, whether primary, secondary, or tertiary, such as hospitals and public or private clinics, can act as supporters, indicating patients(6).

The role of universities can be expanded. By including entrepreneurship education in a way that is appropriate to market realities, they can serve as an incentive for this new professional context, as well as creating study groups to assist new entrepreneurial nurses(6,29). It is also worth mentioning that technology transfer centers for patent registration and technological innovations are present in universities(29).

Another form of support would be the groups of entrepreneurs for exchange of information, such as co-operation, that can be promoted today by technology and the world wide web, by the use of applications or even by telephone, called virtual groups(6).

Many initiatives can be undertaken by legislatures and nongovernmental agencies to encourage nurses to become nursing entrepreneurs by identifying specific niches and adopting actions to encourage health services by entrepreneurial nurses in these segments. Some areas to be considered for new actions in relation to nursing entrepreneurs are: regulatory requirements, group insurance programs, reimbursement procedures, education and training programs, preference in government contracts for specific niches, and budget support for the creation of an office for promotion(6).

The few studies related to the teaching of entrepreneurship show its stagnation in the area of Nursing.

Studies report that self-efficacy, business interests and career choice are more likely to arise in students in business, engineering, and life science disciplines than in Social Science, Humanities and Nursing students. The latter are likely to experience more contextual barriers (personal or financial) that lead them to reject their potential entrepreneurial vocation(31).

Thus, the non-entrepreneurial profile of the students(19) should be taken into account in the elaboration of new teaching policies aimed at the development of this competence. Undergraduate Education should provide nurses with the development of characteristics inherent to the entrepreneurial profile, which include: pursuit of challenging objectives with adequate risk assessment, visualization and use of opportunities, autonomy and independence of decisions, creativity for solutions innovations and professional achievement for success(32).

However, institutional structures themselves hinder entrepreneurial talent in less traditionally entrepreneurial disciplines, such as nursing(31). The university would be focusing on patient management, but not teaching organizational management(6).

Faced with such challenges, the teaching of entrepreneurship in Nursing is reported as essential in most studies and demands more dedication from researchers and teachers(2,12,15,17-19,21-23,31).

It is necessary for nursing educators to adopt the goal of preparing nurses with adequate knowledge and skills to meet the demands of a constantly changing and increasingly demanding professional practice(17), pointing out the need for a formal path or structure for the preparation of future entrepreneurs. The challenge for education and training providers will be to ensure that developed pathways provide sufficient flexibility to individuals so as not to stifle creativity(24).

There is a need to search for their own methods, different from traditional teaching(19), and interdisciplinarity with professionals from other health areas(2). In this sense, the study by Boore (2011) presents the NICENT (Northern Ireland Centre for Entrepreneurship) model of education for entrepreneurship in Nursing, reporting the process of implementation of this model. The conception, the adaptations for the world of Health and Nursing, the integration of relevant theoretical concepts, the validation and the effective implementation of the program, as well as reflections(17).

Study limitations

In addition to the scarcity of updated articles that responded to the guiding question of this study, it was observed that the studies carried out tend to investigate the obstacles, to the detriment of the search for solutions to overcome them, providing few or insufficient answers.

Contributions to the sectors of Nursing, Health or Public Policy

This research is one of the most comprehensive on the subject nowadays, providing valuable insights for understanding entrepreneurship in nursing business. It was identified the lack of preparation of the nurses to act as managers, revealing a gap to be filled in undergraduate education. It is necessary to prepare nurses with the appropriate knowledge and skills to meet the changing demands of the labor market, preparing them as future entrepreneurs.

CONCLUSION

Among the studies reviewed, we have found research that seeks to assess and interpret business entrepreneurship in Nursing in several aspects, emerging the following themes: Entrepreneurship Concepts in Nursing, Being an Entrepreneur Nurse, Business Diversity, Business Management, Barriers, Support to the Entrepreneur Nurse; and Teaching of Entrepreneurship in the Undergraduate Education in Nursing.

There is convergence in the characterization of three ways of undertaking in Nursing, according to the professional's performance, which depends on the dimensions and domains of the professional life of the nurse: the business entrepreneur, the intrapreneur and the social entrepreneur. Certain personal characteristics, attitudes or competencies define the profile of the entrepreneur nurse, as well as impel him to undertake, taking advantage of opportunities.

A range of different niche markets is possible for the enterprising nurse. However, the business sector is influenced by many factors, such as location, economy, legislation and local culture, in addition to those related to the skills of each professional.

In the business management, were found: assessment of entrepreneurships and management guidelines, besides the most common errors, which are related to the lack of preparation of the nurse to act in the management of companies. On the other hand, the various forms of support to become an entrepreneur, such as associations, social organizations and volunteers, are reported.

Regarding the teaching of entrepreneurship in Nursing, the works converge to a consensus in the literature: it is essential and still needs more attention. It is necessary to prepare nurses with adequate knowledge and skills to meet the demands of a constantly changing and increasingly demanding professional practice, preparing them as future entrepreneurs.

This study suggests that other research in the area should be carried out, aiming at new contributions to Nursing by increasing the integration capacity of professionals in the labor market and by improving their own well-being and that of society.

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Received: June 12, 2018; Accepted: July 04, 2018

Corresponding Author: Rosana Maria Barreto Colichi E-mail: rosana@fmb.unesp.br

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