title: Self-employed nurses as change agents in healthcare: strategies, consequences, and possibilities.
abstract: OBJECTIVE
  The purpose of this paper is to report on ethnographic research that investigated how self-employed nurses perceive the contemporary healthcare field, what attributes they possess that facilitate their roles as change agents, what strategies they use to influence change, and what consequences they face for their actions, thus contributing to what is known about organizational change in institutionalized settings such as healthcare.
  
  
  METHODS
  Focussed ethnography was used to explore self-employed nurses' work experiences and elucidate the cultural elements of their social contexts, including customs, ideologies, beliefs, and knowledge and the ways that these impact upon the possibilities for change in the system.
  
  
  RESULTS
  These self-employed nurses reflected on the shortcomings in the healthcare system and took entrepreneurial risks that would allow them to practice nursing according to their professional values. They used a number of strategies to influence change such as capitalizing on opportunities, preparing themselves for innovative work, managing and expanding the scope of nursing practice, and building new ideas on foundational nursing knowledge and experience. They had high job satisfaction and a strong sense of contribution but they faced significant resistance because of their non-traditional approach to nursing practice.
  
  
  CONCLUSIONS
  Despite dramatic restructuring in the Canadian healthcare system, the system remains physician-centered and hospital-based. Nursing's professional potential has been largely untapped in any change efforts. Self-employed nurses have positioned themselves to deliver care based on nursing values and to promote alternative conceptions of health and healthcare. This study offers a rare exploration of this unique form of nursing practice and its potential to influence health system reform.
authors.forename: Sarah
authors.initials: S
authors.lastname: Wall
mesh_terms: D002170:Canada; D003695:Delivery of Health Care / Q000458:organization & administration; D004651:Employment; D016520:Entrepreneurship; D018166:Health Care Reform; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D024802:Nurse's Role / Q000523:psychology; D009726:Nurses / Q000523:psychology*; D009936:Organizational Innovation; D057184:Practice Patterns, Nurses'