EXPLORING PERSPECTIVES OF LEGAL NURSE CONSULTANTS AS
ENTREPRENEURS: A CASE STUDY
by
Evelyn Houston Bell
Copyright 2019
A Dissertation in Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy in Nursing
University of Phoenix
ABSTRACT
Entrepreneurial opportunities exist in the nursing profession for nurses who are seen as innovative, forward thinkers, and have a desire to work independently. Entrepreneurship as a legal nurse consultant is a career choice that allows for that independence while supporting the legal community. Legal nurse consultants use training and clinical experience to provide expert opinions related to practice standards of care and damages.
In this exploratory qualitative case study, the researcher explored the perceptions of legal nurse consultants regarding the journey to become entrepreneurs. The problem that was the focus of this study was absence of sufficient and applicable research identifying the process for legal nurse consultant entrepreneurs developing a successful independent practice. In this qualitative exploratory case study, Albert Bandura’s theory of self- efficacy was the guiding framework, which helped to clarify the capabilities required for success in entrepreneurial business endeavors. Data were obtained from interviews conducted through the use of SKYPE™ with 8 entrepreneurial legal nurse consultants.
The analysis of data included the use of pattern-matching technique and coding of data for evaluation, organizing, and data analysis. Confidence related to performance capabilities and a determination to be successful were the prominent themes, which emerged during data analysis. The data from the results revealed that a level of confidence and determination is necessary during the legal nurse consultant entrepreneurship journey. The study fills a literature gap identifying the pathway for legal nurse consultant entrepreneurs.
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DEDICATION
I dedicate this dissertation to my husband, Carlton, who was compelled to listen when I just needed an ear. You listened to me even when you were certain I had transformed into someone other than your wife. Carlton, you tried to be patient through all the missed special moments and family gatherings. I am so grateful for all the special breakfasts in bed after my all-nighters, and the many times you made sure I stayed hydrated. Carlton, you have been with me through this entire process, and I have so much love and gratitude for sticking with me through this journey. Thank you to my daughter
Nicole who kept me going with her constant support and “evil” eye to ensure that giving up was not an option. I also dedicate this dissertation to my grand daughter Chaise, who was so aware of my need for quiet time. You always asked, “Are you doing schoolwork, or work-work”? Loving memories of my parents, Freddie and Rebecca Houston, and my brother Jeffrey who have been a never-ending source of strength during my journey.
Family, I love you all.
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ACKNOWLEDGMENTS
I would like to thank the participants who were so gracious and willing to support me. I am grateful to my colleagues, sorority sisters, and forever friends that walked with me during this journey, especially Venetra. Dr. Anne Brett (aka Dr. Anne), there are no words to adequately describe your presence during this journey. Thank you so much for your unwavering, awesome, and intentional support and guidance. You were so committed to being present with your undying encouragement. To my committee, Dr.
Cydney Mullen and Dr. Samson Omotoso, thank you so much for your willingness to provide support and valuable feedback.
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TABLE OF CONTENTS
Contents ...... Page
List of Tables ...... ix
List of Figures ...... x
Chapter 1: Introduction of the Problem ...... 1
Background ...... 2
Statement of the Problem ...... 4
Purpose of the Study ...... 5
Significance of the Study ...... 6
Nature and Scope of Study ...... 9
Research Question ...... 10
Theoretical Framework ...... 10
Conceptual Terms ...... 13
Assumptions ...... 14
Limitations ...... 14
Delimitations ...... 15
Summary ...... 15
Chapter 2: Review of Literature ...... 16
Literature Review and Title Searches ...... 16
Historical Content ...... 17
Nurse Entrepreneur ...... 19
Legal Nurse Consultant ...... 22
Concept of Success ...... 24
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Concept of Leadership ...... 28
Role Expectation ...... 29
Entrepreneurship and Global Impact ...... 35
Determining Barriers ...... 37
Self-Efficacy Theory ...... 41
Literature Gap ...... 44
Conclusion ...... 45
Summary ...... 46
Chapter 3: Method ...... 47
Research Method ...... 47
Research Design ...... 49
Research Question ...... 51
Population ...... 52
Sample ...... 52
Ethical and Legal Considerations ...... 55
Data Collection Procedure ...... 58
Data Analysis ...... 66
Summary ...... 71
Chapter 4: Results ...... 72
Summary ...... 99
Chapter 5: Conclusions and Recommendations ...... 101
Conclusion ...... 122
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Summary ...... 124
References ...... 126
Appendix A: Interview Guide ...... 144
Appendix B: Solicitation Letter ...... 146
Appendix C: Informed Consent ...... 148
Appendix D: Theme Development ...... 151
Appendix E: Confidentiality Statement ...... 157
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LIST OF TABLES
Table 1: Summary of Literature Search ...... 17
Table 2: Demographic Chart: Pilot Study Participants ...... 73
Table 3: Demographic Chart: Study Participants ...... 76
Table 4: AALNC Data ...... 94
Table 5: Recommendations...... 118
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LIST OF FIGURES
Figure 1: Triangulation of Data ...... 67
Figure 2: Theme of Determination to be Successful ...... 97
Figure 3: Theme of Confidence Related to Performance Capabilities ...... 98
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Chapter 1
Introduction of the Problem
Entrepreneurial nurses can be described as those who can act independently and focus on application while generating innovative, and fresh ideas (Wall, 2013).
Entrepreneurs are the driving force for the foundation of jobs, financial progression, and innovative ideas (Estay, Durrieu, & Akhter, 2013). Entrepreneurs develop new professional and employment opportunities. Estay and colleagues (2013) also found that entrepreneurs could be seen as risk-takers while appreciating employment independence.
Entrepreneurship as a legal nurse consultant (LNC) provides an alternative career opportunity, and the chance to work independently in a diverse role beyond the hospital walls (Zorn, Caparco, & Burbank, 2016). An entrepreneurial venture or self-employment is an opportunity to work independently as a legal nurse consultant while incorporating nursing skills and knowledge into supportive activities within the legal community (Neil,
2013). The support provided by LNCs often entails the delivery of nursing opinions related to professional events and the standard of practice while interpreting medical data
(Zorn, Caparco, & Burbank, 2016). There is value with the use of legal nurse consultants, which includes performing medical analysis within the context of the legal community (Zorn, Caparco, & Burbank, 2016).
An awareness of what to expect on the nurses’ journey toward entrepreneurship would be valuable in determining how to proceed in the process. Identifying a specific roadmap for emerging nurse entrepreneurs toward independence will provide knowledge to strategize for success. Being aware of the necessary skills for being a successful LNC would offer a unique perspective on entrepreneurship.
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There has been an increase in opportunities for independent practice by nurses other than those in the legal nurse consultant role. Independent practice by nurse practitioners is now possible due to recent health care reform legislation (McMichael,
2017). However, because of state requirements, nurses transitioning into independent practice have been limited (McMichael, 2017). Nurse entrepreneurship is an opportunity to promote and enhance those elements of leadership necessary for success as an entrepreneur (Sherring, 2012).
Chapter 1 includes the background of the study related to the journey for legal nurse consultants toward entrepreneurship. The study used a qualitative exploratory case study approach to offer a sound understanding of the perceptions and viewpoints during the legal nurse consultant’s journey toward self-employment. This study provided an opportunity to bring value to the nursing profession while identifying key factors essential for success as an entrepreneur.
Background
As an advocate for the profession of nursing, LNCs are given the opportunity to also advocate for patients while impacting legal outcomes (Castellana, 2014; Milazzo,
2007). Legal nurse consultants are seen as the medical link with law firm attorneys, clients, expert witnesses, health care providers, and those who are related to legal cases
(Castellana, 2014). Attorneys depend on LNCs to provide the most recent medical research to support the facts and claims of cases (Castellana, 2014). Legal nurse consultants are often charged with having the first look at potential cases, by determining if a particular claim has merit to bring a lawsuit (Castellana, 2014). Interviewing clients is a significant role for the LNC. Reviewing and analyzing voluminous medical records
2 in personal injury and medical malpractice cases helps to give a snapshot of the patient care during health care events (Castellana, 2014). Adherence to practice standards of care is determined by the medical record analysis (Castellana, 2014). With the disposition of cases, LNCs are instrumental in assisting during trial preparation, including preparation of and response to legal documents. In addition to having a presence in law firms, LNCs have also established a place in insurance companies, governmental agencies, and state boards of nursing, in addition to independent practice as entrepreneurs
(What is an LNC, 2019; Castellana, 2014).
Many opportunities within the nursing profession exist outside the familiar health care facility and organization. Brown (2019) described how nurses are especially qualified to own businesses based on the skillset perfected through education and practice. Wilson and colleagues (2012) reported that registered nurses make up approximately 80% of the health care workforce, yet only 0.5-1% are in entrepreneurial roles worldwide. Wall (2014) noted that nurses in general turn to self-employment as an alternative employment option to enrich professional possibilities. Dinu (2015) found that organizations are outsourcing services to help reduce costs while maintaining the quality of service. Culha, Turan, and Kaya (2017) agreed with Titus (2011) in that the growth of entrepreneurs is vital to the development of financial gains.
Some negatives with emerging nurse entrepreneurs from all specialty areas include inexperience and ineffective management expertise (Wan, 2017). Titus (2011) further found that the United States Small Business Administration reported that higher than 50% of small businesses are not successful due to failures during the first year, and a
95% failure within five years. Failures occur due to declining enterprises, often related to
3 errors with management, such as entering into business with questionable motives or lack of business experience and entrepreneurial capabilities (Startup business, 2016; Titus,
2011). The lack of adequate resources for entrepreneurs and expenditures to manage the day-to-day activities is also responsible for business failures (Titus, 2011). Willing to take risks on the journey toward entrepreneurship is an essential achievement of entrepreneurs (Culha, Turan, & Kaya, 2017; Titus, 2011). Awareness of the failure statistics can be seen as a motivator for entrepreneurs to work harder toward success
(Patel, 2015). Wilson and colleagues (2012) emphasized that nurse entrepreneurship promotes innovation that influences change while displaying qualities of leadership.
The process of self-employment for the legal nurse consultant can be challenging to accomplish, as the resources that would bring value for an effective transition are lacking. Summers (2005) confirmed that the LNC’s primary network resource is limited.
With the absence of available resources that provide valuable and honest guidance, frustration is evident with the new and emerging consultant. A clear and candid picture must be shown that provide a realistic direction toward effective movement toward self- employment while limiting the color and glamor of independence. Addressing barriers to independent practice as well as the specific skill set and responsibilities for a successful practice is necessary (Elango, Hunter, & Winchell, 2007).
Statement of the Problem
With the increasing complexities of health care, along with the associated increase in medical litigation claims, there is an increasing demand for legal nurse consultants and increased opportunities for nurse entrepreneurship. Castellana (2014) emphasized the demand for qualified and seasoned legal nurse consultants to meet the needs of those
4 entities and organizations that employ legal nurse consultants. However, there is a lack of useful resources for the emerging legal nurse consultant, as research has a tendency to focus more on the successes of entrepreneurs (Wall, 2013; Wall, 2014). Jahani (2016) discussed how there is hesitancy with a move to nurse entrepreneurship, as a result of previous attitudes that entail adhering to physician orders and engaging in routine tasks.
Dyck (2016) stressed that nursing knowledge and skills would not be enough to propel nurses forward in the business world. With the focus on a new and specialized nursing concentration, a successful transition from employee status to entrepreneurship requires overcoming barriers related to the lack of knowledge and skills to perform successfully as nurse entrepreneurs (Dehghanzadeh, et al., 2016). Fawcett and DeSanto-Madeya (2013) found that with a change in the makeup of various nursing services, legal nurse consulting as a profession could survive. The general problem this study sought to address was the high entrepreneurial failure rate. The specific problem is the absence of sufficient and applicable research that identifies the process for LNC entrepreneurs developing a successful independent practice.
Purpose of the Study
The purpose of this case study was to explore the perceptions of legal nurse consultants regarding the journey to become entrepreneurs. This research study provided a platform for successful legal nurse consultants to describe their personal journey while providing a description of those experiences with an explanation of the spirit and essence of being a nurse entrepreneur. An exchange of ideas was prompted related to entrepreneurship while determining the impact of self-efficacy on entrepreneurial success. Revell-Love and Revell-Love (2016) believed that the measurement of a
5 successful entrepreneurial venture is related to the entrepreneur’s self-efficacy concept.
Densberger (2014) supported Revell-Love and Revell-Love’s (2016) opinions, noting that self-efficacy is a component of, and motivating force behind entrepreneurship.
Having confidence and faith in personal abilities when meeting stated goals and responsibilities speaks to the spirit of the self-efficacy concept (Bandura, 1977).
Confidence is developed as practice independence is developed (Pasarón, 2013). The research findings helped to close the gap in the current body of written works while increasing knowledge related to the experience of the entrepreneurial legal nurse consultant, which will be timely for nursing education, practice, and research. The study provided a gauge and indicator of the necessary steps toward the development of the often forgotten nurse specialty.
Establishing new business entails recognizing opportunities, working through innovative ideas, and accepting risks and fears. Cultivating an entrepreneurial business may bring challenges and unforeseen obstacles. The research contained insight into the fears, risks, and challenges that can be associated with entrepreneurship (Dyck, 2016).
Research Proposition. The proposition for this research study is: successful entrepreneurial legal nurse consultants require a skillset that consist of clinical and legal expertise, and a sense of self-motivation and self-assurance.
Significance of the Study
There is a high risk of failure for those seeking entrepreneurial ventures (Titus,
2011). An exploration of the legal nurse consultant’s path toward entrepreneurship provided some insight into building a successful business. As a result of the risk associated with entrepreneurship and the percentage of business failure, new nurse
6 entrepreneurs can experience intimidation with starting a business (Dyck, 2016).
Acknowledging the demands and obstacles of entrepreneurship for legal nurse consultants has not received as much attention as the successes of entrepreneurs (Elango et al., 2007; Hardy & Maguire, 2008). Estay, Durrieu, and Akhter, (2013) postulated that once a desire has been identified, a truthful personal assessment must occur as to the determination and the required capabilities for success while acknowledging the risks for failure. There is a plethora of research that glorifies the benefits of entrepreneurship, which includes being your own boss and the income potential that exists with self- employment. However, research is devoid of information that explores specific pitfalls and challenges associated with nurse entrepreneurship.
Significance to nursing. The concept of the nurse as an entrepreneur is not
usually related to the practice of health care, and at first glance, might not be apparent to
the work that nurses do (Jahani, 2016; Wilson et al., 2012). This research provided
knowledge for nurses relative to the benefits of entrepreneurship while clarifying and
providing specific information about entrepreneurship in nursing. Grasping the
principles and value of entrepreneurship will help to increase the acceptance of this
alternative career choice. This study focused on the perceptions of the legal nurse
consultants’ experience as entrepreneurs and how those elements might expand into the
profession of nursing and guide practice. Culha and colleagues suggested that some
nurses might be motivated to start a new business based on an unwillingness to adapt to
employer changes. Nurses that possess entrepreneurial personalities, such as innovators,
risk-takers, or a desire to bring about change found that entrepreneurship provides a
7 chance to perform tasks outside the familiar health care system, allowing personal values to develop (Wall, 2013).
Significance to nursing education. The American Association of Legal Nurse
Consultants (AALNC) defines the specialty of legal nurse consulting as registered nurses who use nursing education and clinical skills while supporting legal issues with a medical component (What is an LNC, 2019). Formal training is not a requirement to become a legal nurse consultant, however, participation in an education program would be beneficial as an official overview to the specialty, and to become familiar with the legal process (Education and certification, 2019). Even though nurses can enter this specialty without formal training, the AALNC retains the position that nursing education programs should include legal nurse consulting as a specialty within the curricula (Education and certification, 2019).
With the availability and dissemination of the research findings from this study, nurse faculty in nursing education programs will be provided with the resources to address entrepreneurship in legal nurse consulting as a specialty in nursing. The evolution of nursing roles and the diversity within the nursing profession, which includes entrepreneurship, will be apparent through this research and will be available to those who are in the position to distribute the findings.
Significance to nursing research. The purpose of nursing research is to develop knowledge while providing a supportive structure for nurse practice (Kerr, 2015). Nurses have been placed in a position to assist others in identifying the association between research and health outcomes (Kerr, 2015). This study provided additional information relative to the exploration of the legal nurse consultant’s role as an entrepreneur. An
8 awareness of the path to entrepreneurship may encourage a meaningful change inside the nursing profession by increasing autonomous opportunities. Pasarón (2013) implied that when nurses experience practice independence, a greater sense of confidence is evident.
Nature and Scope of the Study
A case study is a qualitative design approach that sets clear boundaries while considering alternative perspectives (Yin, 2003). Houghton, Casey, Shaw, and Murphy
(2013) believed that a case study was an ideal approach to engage in a deep and intensive examination to obtain insight into an experience. The purpose of this case study was to explore the perceptions of legal nurse consultants regarding the journey to become entrepreneurs.
The scope of the study included legal nurse consultants who have experienced various stages of starting and managing an entrepreneurial business. The study explored the experiences of the participant while focusing on the journey toward entrepreneurship.
The goal of the study was to provide legal nurse consultants with a stage to discuss personal experiences, present a conclusive depiction of those experiences, and provide an interpretation of what an entrepreneur encounters. Exclusions entailed registered nurses who have not practiced as an entrepreneur in the legal nurse consultant role. The study’s population included entrepreneurial registered nurses working in the United States as legal nurse consultants. To obtain detailed and exhaustive data, the sample was a small group of entrepreneurs.
Objectivity and credibility were vital to this study. There was a presumption that the participants honestly disclosed personal experiences relative to entrepreneurship.
Shenton (2004) noted that when participants feel they have the freedom to participate in
9 the study, honesty would occur, leading to candid data. Accurate transcription of the data occurred by repeatedly listening to the recorded interviews and preparing a word for word transcription.
Research Question
Ensuring that the purpose of a research study is achieved, the development of effective research questions is crucial (Gelling, 2015). Gelling (2015) asserted that the consistency of the research questions should provide a connection with the philosophical proposals of the qualitative study. Qualitative questions, such as those that elicit information, related to the experience of participants, allow for the sharing of information
(Gelling, 2015). As such, the one guiding research question for this qualitative case study was:
RQ 1: How do legal nurse consultants describe their journey toward entrepreneurship?
This question was explored through interviews with eight (8) legal nurse consultants via
SKYPE™. The interview guide is presented in Appendix A.
Theoretical Framework
The intent and purpose of a theoretical framework is to provide the basis and foundation for a research study. Alligood (2011) noted that theory guides the ideas and decision-making of the research process and gives meaning to the study findings. For nursing research to have meaning, the theory should be explicit (Alligood, 2011). This qualitative case study was based on the theoretical framework of Albert Bandura’s theory of self-efficacy. Bandura’s framework assisted in directing this study to explore legal nurse consultants’ journey to entrepreneurship. Bandura’s self-efficacy theory was used
10 as the foundation by bringing meaning to the required skills to be successful in entrepreneurial ventures.
Self-efficacy is at the core of Bandura’s social learning theory, which includes the discernment that individuals make about the ability to be successful about a particular task, and the ability to control situations and ambitions (Bandura, 1977). Densberger
(2014) also referred to Bandura’s theory, noting that self-efficacy is a component of, and motivating force behind entrepreneurship. As a Stanford psychologist, Bandura interpreted years of research through the use of a framework that was behavioral and social learning based (Bandura, 1977). The social cognitive theory relates to concepts that involve reasoning and logical thinking (Bethards, 2014). The component of the theory that encompasses the social dimension includes the elements of thought and behavior (Bandura, 2004). The cognitive part of the theory aligns with the procedure related to thought processes (Bandura, 2004). Unless individuals have confidence in following through with their intended actions, there will be little motivation to persevere when facing challenges (Bandura, 2004). The social cognitive theory proposes that the most important predictors of self-efficacy are expert skill, experience, verbal influence, and physiological and emotional conditions (Bandura, 1986).
Self-efficacy is concerned with the determination of an individual’s ability to perform (Bandura, 1986). As self-efficacy is realized with the attainment of goals, motivation is heightened (Bethards, 2014). Unless individuals believe in the possibility of success, there is little motivation to work through any barriers or challenges (Bandura,
2009). Self-confidence is a precursor and basis for success as an entrepreneur while
11 being the foundation of competency and proficiency (Castellana, 2014). There is a correlation between personal abilities, motivation, and action (Bandura, 1997).
One of the critical elements of entrepreneurial success is self-confidence
(Castellana, 2014). The theory of self-efficacy played a role in the qualitative research process in discerning the level and depth of entrepreneurial success. The theory of self- efficacy draws on the belief that individuals are contributors to personal situations and events, rather than being a product of them (Bandura, 2009). Bandura (1997) believed that people must have a desire to be productive. As entrepreneurs move toward success, elements of the self-efficacy concept are recognized. Perceived self-efficacy is concerned with the confidence in one’s ability to follow through with an action to produce results (Bandura, 1997). Taking on new ventures depends on self-efficacy as a significant role in the process (Bandura, 2009). Understanding that there can be unforeseen risks, and making the decision to move forward with entrepreneurship in spite of those risks, is directly related to self-efficacy as an entrepreneurship (Bandura, 2009).
Bandura’s self-efficacy theory provides a framework for the entrepreneur’s commitment, intentions, and the ability to be a successful entrepreneur. A person’s belief in self- efficacy has many distinct effects. The belief in self-efficacy is related to a person’s commitment, persistence, and determination, to not just choose a path, but to persevere throughout any challenges and obstacles (Bandura, 2009).
Self-efficacy includes theoretical implications related to the success of entrepreneurs, as new ventures demand the ability to possess a distinctive skill set (Chen,
Greene, & Crick, 1998). Well-defined roles for the entrepreneur are not always obvious.
Entrepreneurs may feel many uncertainties as to the desired business success. Assuming
12 that an entrepreneur can successfully fulfill tasks with motivations, the self-efficacy theory emphasizes that the quality of a task is reliant on the entrepreneur’s belief in their capabilities. A positive result is likely for those entrepreneurs who possess a high level of self-efficacy, with the ability to be successful. Therefore, the movement during the entrepreneurial process can be streamlined.
Conceptual Terms
Entrepreneur: An entrepreneur can be considered as someone who generates or establishing something new, is innovative, a motivator, and does something different
(Estay, Durrieu, & Akhter, 2013).
Successful entrepreneur: A successful entrepreneurship could be described as a business showing profit along with an increase in personal wealth (Makhbul & Hasun,
2011). A business that has been in operation for greater than 3 years reflects a successful entrepreneurship (Dafha, 2008).
Entrepreneurial journey: The entrepreneurial journey begins from the inception of an idea for a business venture to an established business (Estay, Durrieu, & Akhter,
2013). The journey is the process and duration of gaining experience for the entrepreneur.
Legal nurse consultant: A legal nurse consultant is a professional registered nurse
(Neil, 2013). Legal nurse consulting is described by the American Association of Legal
Nurses Consultants (AALNC) as a professional nurse capable of providing support in medical-legal cases, which include evaluations as to the standard of care, causality, and injury, as a result of professional nursing education, training, clinical experience and expertise (What is an LNC, 2019).
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Self-efficacy: Self-efficacy is related to an individual’s belief and confidence in the ability to accomplish a task (Revell-Love & Revell-Love, 2016)).
Assumptions
An assumption for the study was that the approach and procedure for choosing the study participants would not provide biased data. Another assumption was that the participants offered truthful and straightforward responses and a precise accounting of the journey toward entrepreneurship. Strict confidentiality of the participants was maintained to encourage candid and truthful facts and information. Bracketing was used as a safeguard to assist in acknowledging personal views and preconceptions. The use of bracketing to interrupt the beliefs was used to avoid bias and enhance trustworthiness
(Tufford & Newman, 2012).
Limitations
Study limitations are obvious in all studies and reflect situations that are challenging to control. A limitation of this study was the access to participants. There was difficulty with finding participants that could devote time for data collection.
Finding candidates began with the American Association of Legal Nurse Consultants.
The exploratory case study approach presented a limitation, as the information obtained from participants required examining the experiences of the entrepreneurs through self- reporting. The expectation for the study participants was to offer information as a result of experiences (Rolfe, 2006). Data collection was accomplished with the use of interviews with the participants using SKYPE™ via Internet capabilities. There was a possibility that the reported data would consist of biased sources. An additional
14 limitation is that the events may not have been remembered as accurately as they were presented. Some events might have been remembered better than others.
Delimitations
Delimitations are an opportunity to limit the scope of the study. Registered nurses who are not entrepreneurs were not recruited for this study. Entrepreneurs who are not legal nurse consultants were not recruited for this study. Because information obtained from experience entails retrieving information retrospectively, the use of experienced entrepreneurs may have led to memory distortion.
Summary
Chapter 1 incorporated an introduction of (a) legal nurse consulting as an alternative for a nursing career, (b) insight into entrepreneurship, and (c) entrepreneurship as a legal nurse consultant. The study used the qualitative exploratory case study approach to increase awareness of the path to entrepreneurship. Chapter 1 outlined why the research brought value to nursing, identifying essential factors that shape the journey of the emerging legal nurse consultant. Chapter 2 consists of a literature review that reflects the historical and current perspectives that guided this study.
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Chapter 2: Literature Review
The purpose of this qualitative case study was to explore the perception of legal nurse consultants related to the journey to become an entrepreneur. The goal of this study was to provide a platform for legal nurse consultants to articulate and convey the personal journey to entrepreneurship. This literature review shows the capacity for obtaining knowledge related to the entrepreneurial process. Randolph (2009) asserted that the literature review is a validation of knowledge. Having a good grasp and understanding of the literature related to the study is necessary before conducting significant research (Boote & Beile, 2005). Chapter 2 provides literature findings that represent the face and characteristics of legal nurse consulting, the background of entrepreneurship, the history of entrepreneurship in nursing, the entrepreneur role expectations, and the use of the self-efficacy theory in current research related to entrepreneurship.
Title Searches, Articles, Research Documents, and Journals
A literature review was achieved using articles obtained from peer-reviewed and scholarly journals. The literature search included sources from 1991-2019, with the exclusion of those sources used to offer the historical context. The terms “legal nurse consultant”, “legal nurse consulting”, “nurse consulting”, “entrepreneur”, “nurse entrepreneur”, “history of nurse entrepreneurship”, entrepreneur and role expectation, and
“Self-Efficacy Theory” were used when searching conventional methods, and online databases EBSCOhost, PubMed, ProQuest, and search engines on the Internet. Table 1 reflects a snapshot of the literature search. The historical context of the concept development of entrepreneurship and the formation of legal nurse consultants as a career
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choice is included in the literature. While a substantial number of sources related to the
entrepreneurial process were found, there were limited sources specifically related to the
nurse entrepreneur and the legal nurse consultant entrepreneur.
Table 1
Summary of Literature Searched by Categories
______
Search term (s) Peer-Reviewed Articles Dissertations/Theses
______
Legal Nurse Consultant 52 1
Legal Nurse Consulting 112 0
Nurse Consulting 135 0
Entrepreneur 540 3
Nurse entrepreneur 290 0
History of nurse entrepreneurship 238 0
Entrepreneur and role expectation 62 0
Self-Efficacy Theory 156 0
Historical Content
The word entrepreneur implies getting things finished or completed (Price, 2006).
The original meaning of the word entrepreneur is an individual with ingenuity and
resourcefulness (Price, 2006). Entrepreneurs have been an intangible symbol during the
history of economics (Herbert & Link, 2006). The word entreprendeur was an earlier
form of entrepreneur, which appeared in the 14th century (Herbert & Link, 2006).
However, Richard Cantillon, a well-known philosopher from the 18th century, narrowed
17 the meaning of entrepreneur (Herbert & Link, 2006; Higgs, 1891). Entrepreneur was at that time used as an element in the analysis of the economy (Herbert & Link, 2006;
Higgs, 1891). Cantillon did not distinguish entrepreneurs as a part of a social class, as there were occasions of uncertainties, referring to beggars and robbers as entrepreneurs
(Herbert & Link, 2006).
Entrepreneurship is a significant component in the outlook for economic success.
However, Lee (2017) stressed how there is insufficient empirical research, which examines entrepreneurship influence on economic growth. As a result of the worth of entrepreneurship related to the growth of the economy, assistance from organizations is desired to assist with success; yet, the success of entrepreneurs is not being seen in many regions (Morris, 2002). Several characteristics have been linked with the entrepreneur, such as risk-taker of uncertainty, pioneer, decision-maker, director of resources, and negotiator (Herbert & Link, 2006). Entrepreneurs are innovators that have a drive to undertake or assume challenges while initiating causes for change (Harding, 2006).
Further noted by Harding (2006), is the suggestion that the increase in productivity in the early 1990s was due to the activities of entrepreneurs. As a result of those entrepreneurial activities, policy-makers were moved to create opportunities to support entrepreneurial business enterprise (Harding, 2006).
When looking at the millennial entrepreneur, a downward trend has been reported for 2014 (Advocacy report examines the millennial entrepreneur, 2016). According to the U.S. Small Business Administration, not more than 2% of those categorized as a millennial has reported self-employment in 2014, compared to 7.6 % for generation X
(born 1963 to 1981) and those categorized as baby boomers (born 1944 to 1962). The
18 current landscape for the millennial reflects a sliding trend for entrepreneurship
(Advocacy report examines the millennial entrepreneur, 2016). Current reporting shows
11% of millennials in 2014 ascribe to be self-employed, while greater than 47% of millennials are employed (Advocacy report examines the millennial entrepreneur, 2016).
Working toward creating an environment that is more alluring and attractive for the entrepreneur is essential (Advocacy report examines the millennial entrepreneur, 2016).
Nurse Entrepreneur
Smeaton (2003) highlighted the alluring and appealing nature of entrepreneurship related to the autonomous capabilities. The current autonomy is not new to the profession of nursing, as nurses worked independently during the 1920s to meet the health care demands in rural areas (Faugier, 2005; Fitzpatrick, 1975). Menard (1987) noted that nurses were instrumental in providing in-home care independently before
World War II. Nursing began with illustrations of social entrepreneurship that supported efforts to eliminate poverty in attempts to influence the health of the community (Faugier,
2005). However, as hospitals were established, the movement of nurses from the community to those facilities occurred (Dayani & Holtmeier, 1984; Faugier, 2005). The
1980s saw an explosion of pioneering nurse entrepreneurs (Dayani & Holtmeier, 1984).
The current circumstances are right for nurses to engage in independent practice, especially since nurses have a proven efficiency in the health care system. Coupled with a desire for employee satisfaction and changes within the health care system, entrepreneurship as a career alternative seems like a viable choice.
The current trends related to the capabilities for independent nursing practice, provide an incentive and drive to control opportunities and possible income growth.
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However, Drennan and colleagues (2007) reported that the number of nurses acting entrepreneurially remains small. Drennan and colleagues reported on an integrative literature review methodology of published and non-published literature. The different items included research papers based on observation and experiment, theoretical review works, opinion papers, individual personal accountings, journalism articles, and news articles. The purpose of the study aligned with the identified problem, which was to examine the degree to which nurses, midwives, and health visitors are engaging in entrepreneurial activities in the United Kingdom and the things which impact those activities. Drennan and associates examined bibliographic databases, finding that there was limited evidence of entrepreneurial efforts by the nurses, midwives, and other health professionals in the narrative reports. Only three experimental studies were identified while examining 154 items, which highlights deficits of research on entrepreneurship. As a result of the integrative literature analysis by Drennan and partners, the authors concluded that an experimental investigation into the call for entrepreneurship for nurses and midwives should consider the multifaceted interchange of the background and previous experience and that research studying entrepreneurial activities was devoid.
However, there is no data to support a conclusion as to whether there has been an increase or decrease in entrepreneurship. But, as changes associated with nursing are observed, there is a greater understanding related to the roots of the profession and how past experiences help to mold future experiences (Hinck, 2011). Further exploration is needed as to the depth of knowledge and experience required for professional development as a nurse entrepreneur.
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Nursing educational programs consist of a comprehensive or broad perspective that entails the skills necessary for a successful entrepreneurial business. However, Wall
(2013) in a focused ethnographic study, found that less than 1% of registered nurses are included in the sector of entrepreneurial efforts that consist of the self-employed nurse shift from existing organizational positions. A disruption in the work that nurses do, along with stressors in physician-dominated services, the nurses’ recognition as to work contributions is lacking. The purpose of Wall’s (2013) study supported the identified problem, which was to illustrate the essential issues related to the work that nurses do and the contribution to the delivery of healthcare as change agents. Recruitment was with association of registered nurses in private practice, who were self-employed for a minimum of 18 months, along with snowball sampling recruitment. The study sample included 20 nurses. Data collection occurred through interviews, in which dysfunction was reported, as well as, mistreatment, and disrespect to those in nursing. Data saturation was obvious, such that the cohesiveness of the participants’ feelings and ideas was evident in spite of the diverse nature of the practice backgrounds. Opting to seek entrepreneurship was fueled by the restraints placed on nursing related to the ability to use innovative and creative ideas (Wall, 2013). The results of this study show importance and meaning as to possible advancement and potential career choices for nurses, including the efficient use of nurses. Wall (2013) concluded that the nurse entrepreneur has not been the beneficiary of a supportive health care system entirely. In spite of the call for change in the makeup of health care, many issues remain unanswered, which include the support for nurses who seek practice independence. Substantial research is not evident, which could guide and provide meaning to those seeking a
21 professional change. Identifying additional insight related to the benefits of nursing entrepreneurship remains an area that could be extracted from additional research.
The history of nursing validates how nurses can capitalize on the acquired skills, information, understanding, and experiences, to manage the demands of a role change to entrepreneurship (Smeaton, 2003). With the shortage of other health care providers, there is a push for additional roles by nurses (Howkins &Thornton, 2003). Throughout the 1970s and 1980s, corporate entities searched for methods to increase profit and decrease expenses (Bemis, 2011). Consequently, employees experienced loss of jobs and elimination of benefits. Health care organizations also found the need to increase profit, leading to the elimination of not just positions, but entire departments. As a result of those actions, Bemis suggested consulting opportunities developed for nurses.
Compensating a consultant was not as costly as paying a full-time employee with benefits. The insurance industry was also searching for different approaches to assist insurance adjusters with interpreting medical issues associated with claims.
Rehabilitation nurses or workers compensation nurses were used to satisfy those needs, and are now termed legal nurse consulting, case management, or life care planning.
Bemis posits that the legal nurse consultant role quickly expanded as groundbreaking efforts were made to integrate nurses’ expertise to law firms and the insurance industry.
Legal Nurse Consultant
A legal nurse consultant is a professional registered nurse (Neil, 2013). Legal nurse consulting is described by the American Association of Legal Nurses Consultants
(AALNC) as the application of nursing knowledge obtained through training and clinical experience to the examination of standard of care, causality, injury and losses, associated
22
with medical issues in medical-legal cases (What is an LNC, 2019). In spite of nurses
working with attorneys since the 1970s, the specialty of legal nurse consulting was
identified as a specialty within the last decade (Chapter history, 2016). Neil (2013)
reported that legal nurse consulting started in the middle of the 1980s. As a pioneering
legal nurse consultant, Vicki Milazzo began a legal nurse consulting education program
in 1982 (Bradley, 2015). The American Association of Legal Nurse Consultants
(AALNC) was formed in 1989 to develop careers of nurses employed in the legal
industry (About us, 2019). The first legal nurse consulting certification exam, which
reflects expertise in the nurse specialty area, was offered through AALNC in 1998
(Bradley, 2015).
Bemis (2011) noted that nurse consultants were practicing in entrepreneurial roles by the mid-1980s in many different organizational entities. The National Nurses in
Business Association (NNBA) was born out of the reported need for a support system to make business contacts with other nurse entrepreneurs (Bemis, 2011). The NNBA is instrumental in providing information to assist nurse entrepreneurs in being successful
(NNBA).
Career shifts reflect a commitment to a different path (Capella, 2005). Increased control over one’s career trajectory has been an advantage of the entrepreneurial LNC
(Beerman & Watson, 2005). As nurses develop skills consisting of leadership, effective communication, collaboration, effective writing and research abilities, and the ability to work through challenges, Beerman and Watson suggest the development of business acumen occurs and can catapult into entrepreneurship. Self-assurance, capabilities, and knowledge are needed to venture into entrepreneurial legal nurse consulting
23 opportunities. Nurse entrepreneurship continues to evolve while making significant contributions to many different entities.
Concept of Success
Characteristics that are just as important as networking include a high level of self-confidence and determination, education, and experience, which are necessary for entrepreneurial success (Wilson, Averis, & Walsh, 2003). Baum, Locke, and Smith
(2001) echoed the impact of personal characteristics on entrepreneurial success.
Engaging in activities such as networking is instrumental in being successful as an entrepreneur (Wilson et al., 2003). Considering the influence on the ability to generate revenue and profitability, entrepreneurial success has a huge impact on the economy
(Sarasvathy, 2004). Having the stamina to sustain entrepreneurial ventures will also influence success (Van Pragg, 2003). However, Simpson, Tuck, and Bellamy (2004) believed that it was the purpose of the industry that determined the level of entrepreneurial success. Success associated with entrepreneurship is related to an area or locality (Renski, 2006). Dobrev and Barnett (2005) discussed how leadership capabilities propelled entrepreneurial success. Swiercz and Lydon (2002) agreed with Dobrey and
Barnett that entrepreneurial leadership abilities fueled the level of success.
A significant proficiency related to entrepreneurial success is having a strong financial acumen in place. Having financial stressors related to capital deficits can place undue strain on businesses from the outset (Boone & Kurtz, 1990). Small businesses are reliant on the fiscal attributes and the potential of the business (Miller, 1988). Therefore, a clear and precise foundation of financial knowledge is necessary when looking forward to a successful entrepreneurial business.
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Technological advances have led to significant shifts in how businesses operate.
Having a technological knowledge is not an option, rather a needed competency.
Innovative technology approaches have been the boost needed for the success of many entrepreneurs (Kerstetter, 2004). New technology has been a key element in the race for new prospects in the competitive market (Kerstetter, 2004; Presnell, 1999).
Obtaining knowledge of the industry through research and networking helps with gaining insight into the specific product. However, small business owners are reactive, frequently going about the tasks associated with the business, leaving little time for activities associated with research, improvement, or implementing a plan (Monk, 2000).
Entrepreneurs should have a clear concept of the intended business product. Monk noted that responsive rather than proactive behavior is a barrier to success.
Carving out time for the entrepreneur is a struggle, as most are concerned with success without any delays. Business operations are often unorganized (Pineda, Lerner,
Miller, & Phillips, 1998). Maintaining control is frequently a characteristic of the entrepreneur, especially with problem resolution. Delegation of duties rarely occurs.
There is the mindset that no one else is capable of resolving the problem, and will do whatever it takes to maintain control while making corrections (Kruger, 1991).
Determining what impacts time commitments will be a determinant for entrepreneurial success.
Goal setting as an outcome of self-reflection supports the learning process and ultimately business success (Kleiner & Roth, 1998). Learning from experiences entails engaging in conscious efforts to reflect on gaining additional information (Nonaka &
25
Takeuchi, 1995). A commitment to gaining additional knowledge helps as a motivating force for entrepreneurial success.
Entrepreneurship is an opportunity to change and provide excitement to the nursing profession (White & Begun, 1998). Roggenkamp and White (1998) contended that the nurses’ devotion to nursing is an impetus that propels one to entrepreneurship; a notion shared by Boyd and Vozikis (1994). In the exploration of the association between the economic environment and the socio-political environment, Tanas and Audretsch
(2011) echoed that a benefit of entrepreneurship consisted of entrepreneurs facilitating the well being of others due to drive and persistence. With the change in the health care climate associated with the recent passage of health care reform, there has been an increased need along with significant opportunities for nurse practitioners. Career choices for nurse practitioners include independent practice. Howkins and Thornton
(2003) implied that nurses desire to be released from constraints, while yearning for increased flexibility opportunities.
Becoming an entrepreneur, going against the grain, or being in direct contrast to the traditional nurse practice within an organization was emphasized in the Elango,
Hunter, and Winchell (2007) qualitative exploratory research study. The intent of the study was to pinpoint obstacles to entrepreneurship and to propose ideas on resolving those barriers. The possible success with this specific discipline was found to be of interest, as very little is acknowledged of this practice deviation. The purpose of the study supported the identified problem, which discussed the lack of literature focusing on specific influences that impede readiness toward entrepreneurship. Elango and his associates used two focus groups in the study. One group consisted of hospital
26 administrators, entrepreneurs in nursing and ophthalmology, and a nursing school dean.
The other group was 20 nurse practitioner students. The data obtained aligned with the literature associated with regulatory barriers, which included compensation, and cynicism from other health care providers related to nursing practice independence. Elango and partners concluded that collaborative attempts by nurses, professional organizations, and public policy, could catapult efforts in overcoming any challenges to entrepreneurship to support success. While barriers including conflicts were identified in this study, further research would help to validate the obstacles that occur with nurse entrepreneurship.
Through the use of a two-round Delphi Technique and grounded theory, Wilson and colleagues (2003) focused on the understanding and insight into self-employment.
Problems related to the lack of meaningful understanding of quality services of the self- employed nurse, propelled the authors to study the understanding and vision into self- employment and business operations. Round one of the study consisted of a questionnaire which elicited opinions related to attitudes and practices of nurses engaged in business.
Round two involved collating opinions and forming statements obtained from round one.
There were 59 self-employed nurses in round one and 54 self-employed nurses in round two. The findings included significant themes related to the experiences of the nurses.
The study results identified areas that pinpointed experiences during the transition to independent practice and business consideration. The themes that emerged from the data showed that nurses were in accord in the areas of influences, pros and cons, education, knowledge, and barriers (Wilson et al., 2003). However, less agreement was shown related to postgraduate training. Wilson and associates concluded that increases in entrepreneurial success occur with an awareness of behaviors that impact business
27 performance. Further investigation could help determine the reasons or bring some explanation, as to those areas that continue to prompt discussion.
Concept of Leadership
Leadership capabilities impact the extent of entrepreneurial success (Swiercz &
Lydon, 2002). Nurses are being charged with engaging in innovative and entrepreneurial roles (Sherring, 2012). Having a determination and initiative to lead for change is the goal and motivation for entrepreneurship (Wilson et al., 2012). With increasing demands for effective care, the opportunity for diverse roles for nurses is required that entails increased responsibilities. Danna and Porche (2009) discussed how leadership capabilities evident in the nurse entrepreneurial role are dependent on the demands that occur in leadership opportunities. Competencies and expertise define the required abilities and characteristics an entrepreneurial nurse would have to achieve a leadership undertaking (Danna & Porche, 2009). Leadership skills offer a basis from which other competencies develop (Danna & Porche, 2009).
Educational opportunities that consist of leadership components are needed to groom nurses for roles that resemble entrepreneurship as a career choice.
Entrepreneurship is an optimal role to fit the vision in preparing nurses for leadership in the changing health care climate. An ethnographic study was used to explore the perception of the healthcare system and the qualities held as change agents (Wall, 2014).
Wall’s purpose aligned with the perceived need to identify strategies for grooming nurses for entrepreneurial roles. Wall (2014) explored the work experiences of the self- employed nurse, including philosophies and beliefs that influence leadership and change agent capabilities. Recruitment occurred through the association of registered nurses in
28 private practice (ARNPP) by email, with additional recruitment through snowball sampling. Data collection occurred through interviews with 20 self-employed nurses; 19 female and 1 male. A western Canadian province was used, with varied practices.
Interview questions were centered on motivations that prompted self-employment, as well as challenges and facilitators met. Results from data collection revealed a general uneasiness about institutionalism of the health care industry related to economics and efficacy. The nurses believed there was a distinguishing feature about themselves because of their innovativeness for practice choice. The use of entrepreneurship to capitalize on institutional change was a strategic move. Wall postulated that leadership as an entrepreneur enhanced the opportunities and purpose as an agent for change within the health care system. A sense of leadership and strength while in the entrepreneurial role promotes innovations within the health care system. Research findings verified that nurse entrepreneurs were the leaders and visionaries of nursing, committed to developing the role of nursing. However, conflict and opposition are felt due to the non-traditional path to nurse practice. Wall (2014) concluded that having the ability to convey the value of the independent role and business success, played a part in confirming the worth of the practice change and their work. Wall further noted that the professional potential for nurses is essentially unexploited and uncultivated. As a result of this untapped area, additional research might provide information to improve or enhance the change process toward entrepreneurship.
Role Expectation
Entrepreneurship is a challenging role change (Caffrey, 2005). The purpose of
Caffrey’s (2005) qualitative ethnographic study was to explore the approach and
29 challenges associated with entrepreneurship role expectations, and advocacy. Caffrey’s purpose aligned with the belief that there are limited nurses that possess the acumen to develop practice independence. Interviews were conducted including 7 nurses with developing entrepreneurial roles, and 6 clients positioned in a rural community-based environment. Results from data collection revealed there is a need for the entrepreneur role development in nursing. Barriers were identified, which included ignorance and confusion of the entrepreneurial role, financial issues, management of time, and legal issues. Flexibility with time commitments was a plus for the nurse entrepreneur. Being cognizant of legal ramifications with task delegation was also identified; being aware of liability is critical to the entrepreneur. Caffrey concluded that preparations for nurses to perform as entrepreneurs is needed, which includes time, skill development in organizational and financial management, and legal issues. With the identified challenges related to the entrepreneurship transition, additional empirical investigation is needed to ensure that a successful role change is made.
Meiner (2005) believed that role significance was principally related to adherence to the American Nurses Association’s scope and standards of nursing care, and the specific state’s nurse practice act. Within the scope of the LNC role, expert witness testimony is also needed related to professional behaviors (Meiner, 2005). Those in the legal community depend on the probing nature of the legal nurse consultant to assist with the discovery and trial processes.
However, nurse entrepreneurs have been expanding the capabilities of the nursing profession, which require strong leadership capabilities (Faugier, 2005). With an increased demonstration of value, consisting of high-quality performance, there is a
30 greater advantage to hiring entrepreneurial legal nurse consultants (Zorn, 2015). Legal nurse consultants are being viewed as valuable assets to the legal industry (Castellana,
2014). Entrepreneurship seems to be a natural transitional role for nurses, as decision- making, organization, and assessment, along with other leadership duties, occur daily
(Faugier, 2005). Burch (1986) agreed with Faugier, noting that entrepreneurs are intuitive, with very good organizational skills, and are goal-directed.
The research study by Örtqvist, Drnovsek, and Wincent (2007) was drawn from general management, role theory, and entrepreneurial literature to establish hypotheses, with the use of hierarchal regression methods. The purpose of the study was to explore role expectations, and coping strategies to measure entrepreneurial performance. This study supported the need to focus on the harmful consequences that occur as a result of not adhering to role expectations. Örtqvist and colleagues hypothesized: 1) redefining a structural role positively impacts performance with new undertakings, 2) redefining a role on a personal level adversely impacts performance, 3) new venture success is positively impacted by reactive role behavior, 4) new venture success is negatively impacted by passive role behavior, 5) the relationship between redefining a structural role and new ventures is moderated by entrepreneurial role stress, 6) the relationship between redefining a role on a personal level and new ventures is moderated by entrepreneurial role stress, 7) the relationship between redefining a reactive role behavior and new ventures is moderated by entrepreneurial role stress, and 8) the relationship between a passive role behavior and new ventures is moderated by entrepreneurial role stress.
The sample in the Örtqvist and colleague’s study consisted of 183 entrepreneurs of the target population of Slovenian entrepreneurs who identified as having an active small
31 business, with an opening date between 2000 and 2006. Random grouping of 300 cases from each of the years from 2000 to 2006 occurred. The criterion was met for 1800 of the entrepreneurs, and questionnaires with a request to participate in the study were mailed. There were 300 returned questionnaires, however, 114 were removed for not being suitable for the criteria. Males represented 68% and 37% represented previous new business experience. The average age was 40, with a range between 24 and 64. Data results revealed that as entrepreneurs’ perceived expectations are restrained, performance related to business ventures are negatively impacted (Örtqvist et al., 2007). The variables were measured on a seven-point Likert scale to record the new venture performance and coping strategies. Four items measured structural role redefinition; the construct’s
Cronbach’s was 0.71 (Örtqvist et al., 2007). Seven items measured personal role redefinition; the construct’s Cronbach’s was (Örtqvist et al., 2007). Five items measured passive role behavior; the construct’s Cronbach’s was 0.64 (Örtqvist et al.,
2007). Six items measured reactive role behavior; the construct’s Cronbach’s was 0.80
(Örtqvist et al., 2007).
Örtqvist and partners concluded that coping strategies positively impact performance outcomes related to expectations, and there is a relationship between the entrepreneur’s roles, including approaches to cope, which is crucial to meeting the stakeholders’ needs. Switching to an independent role could be complex, which may require nurses to abandon the subservient role. Further research as to the role transition would greatly impact the level of success. Howkins and Thornton (2003) noted that when there is any conflict or struggle related to the role and the perceived role, sustaining the acquired role is not likely. Developing abilities, such as the decision-maker, and
32 actively functioning in roles in all areas of the health care system are necessary (Howkins
& Thornton, 2003). Legal nurse consulting is a much-desired area of practice that entails maintaining practice competency while working within this specialized role. White and
Begun (1998) found that as nurses realize that employer expectations are not conducive to professional growth and a career path, the move toward entrepreneurship is appealing.
There are risks associated with the entrepreneurial journey (Faugier, 2005; Wall,
2014; Wu and Knott, 2006). A qualitative study of nurses by Roggenkamp and White
(1998) explored enthusiasm and performance, in which nurse entrepreneurs were described as confident risk-takers. Nurses’ training is such that the approach to patient care is holistic. That holistic outlook places nurses in a position to be critical, innovative thinkers, and in alignment with the purpose of the study to determine the motivation of a nurse in starting a business (Roggenkamp & White, 1998). A purposive sampling approach was used with successful nurse entrepreneurial graduates. Twenty different themes emerged from the interviews conducted with 4 nurses (Roggenkamp & White,
1998). Data collection revealed findings, which were consistent with motivations, behaviors, and nurse attitudes (Roggenhamp & White, 1998). The findings included the influences that prompted the desire for entrepreneurship, the empowering and immobilizing factors or barriers, which contribute to establishing a business, and the rewards of entrepreneurship (Roggenhamp & White, 1998). Understanding what motivates a nurse to engage in entrepreneurship helps in identifying a potential entrepreneur. The participants revealed qualities, which paralleled each other related to taking risks, assertiveness, and leadership. The findings from the Roggenkamp and White study, which focused on motivation and attitudes, revealed that with an understanding of
33 the entrepreneur’s motivation, capitalizing on the entrepreneurial spirit is possible.
Roggenkamp and White concluded that with continual environmental changes, the need for entrepreneurial support should be acknowledged.
Vereshchagina and Hopenhayn (2009) relied on literature to develop a theory of endogenous entrepreneurial risk-taking, which identified the relationship between the tolerance of entrepreneurial risk and persistence. Deciding to remain in the role of a worker, save, and then pursue entrepreneurship, lessens the risk, while having the flexibility to enter into entrepreneurship. The delayed start or an immediate start will relate to the willingness to accept risk and the perceived benefits associated with expected costs (Vereshchagina & Hopenhayn, 2009). The likelihood of engaging in risky activities will be dependent on the level of patience of the entrepreneur (Vereshchagina &
Hopenhayn, 2009). Vereshchagina and Hopenhayn presumed that entrepreneurs want riskiness for the journey while noting that poorer entrepreneurs would be more inclined to assume risks (Vereshchagina and Hopenhayn, 2009).
Wu and Knott (2006) suggested that confusion exists between demand uncertainty and ability uncertainty related to the knowledge of entrepreneurial risks. Entrepreneurs are just as opposed to risk related to demand uncertainty, however, they possess a level of self-confidence, describing the dislike for the conservative risk characteristics. Norton and Moore (2006) supported this insight in a qualitative exploratory study. The study’s purpose was to examine risk assessment and the suggestions for entrepreneurial business decisions through simulation (Norton & Moore, 2006). The sample size was comprised of 30 entrepreneurs and 23 non-entrepreneurs. An original questionnaire was used to exam risk assessment. A state society membership database was used to recruit
34 participants. There was a random selection of 500 members. There were 32 undeliverable questionnaires. There was a response rate of 11%, which reflected 53 applicable questionnaires. Entrepreneurship was identified with 56% of the respondents.
Entrepreneurs identifying as risk-takers were a mean of 11.633, with a mean of 13.130 for risk-taking for non-entrepreneurs. The difference between the means was not statistically significant (P < 0.3496) (Norton & Moore, 2006). Data collection revealed findings that showed entrepreneurs exhibited no difference with risk-taking potential from the non-entrepreneur, and entrepreneurial performance is associated with risk appraisal. Entrepreneurs were more optimistic with risk than the non-entrepreneur
(Norton & Moore, 2006). Norton and Moore concluded that the tendency for risk-taking is based on characteristics and that the measured assessment of risk is related to the information received. Entrepreneurs are those seeking new challenges and are willing to accept the risks (Wilson et al., 2003). Wilson and associates (2003) further suggested that a nurse entrepreneur was considered an individual who anticipated risks associated with a business venture.
Entrepreneurship and Global Impact
Besides the competencies that reflect effective leadership abilities, the integration of cultural competence is critical within the global component of the entrepreneurial practice (Danna & Porche, 2009). Engaging in ethical practice is a professional responsibility and ethical obligation. Komives and Arminio (2011) agreed that performing to a standard reflective of best practice supporting global initiatives while upholding integrity is a professional expectation. However, Austin (2001) questioned the possibility of engaging in an ethical practice framework within a global setting, when
35 looking at diverse cultures. Danna and Porche (2009) insisted that the business plan and approach for the nurse entrepreneur should include a global component.
Justice is vital to global health care (Global health ethics: Key issues, 2015).
Legal nurse consultants in the entrepreneurial role bring value in the attempt to influence the health of communities through efforts related to justice (White & Begun, 1998;
(Global health ethics: Key issues, 2015). In the context of ethics related to the delivery of global health care, access to good health is an important ethical principle (Global health ethics: Key issues, 2015). Unfortunately, adequate health care is not easily available to a large group of individuals. Fair and equal treatment is essential to health care delivery.
Health care is put at risk in communities with limited resources, such as those in poor living conditions (Global health ethics: Key issues, 2015). A plea for global justice is critical to promoting global health equity (Global health ethics: Key issues, 2015). With the changing health care needs of populations, legal nurse consultants add value to ensure the viability of quality health care (Gerris, McDonnell, & Kennedy, 2013). Looking at the global perspective and the need and influence of legal nurse consultants, it is evident that there are global issues affecting health care and nursing, which have legal implications (Gerris et al., 2013).
Javidan and House (2001) stressed the importance of executives having a working knowledge of the cultural discrepancies and resemblances between countries. Carlsson,
Acs, Audretsch, and Braunerhjelm (2009) discussed claims that entrepreneurship has a more significant position in the United States than in other locations, such as Europe and
Japan. Carlsson and associates established a model that distinguished between knowledge with an economic component and general knowledge. There was a question
36 relative to innovative economic undertakings, noting that entrepreneurship was the association that was missing between financial knowledge and economic growth and development (Carlsson et al., 2009). An investigation was pursued related to establishing knowledge, entrepreneurship, and financial development in the United States. The state and condition of the economy is dependent on acquired knowledge and the conversion of that knowledge into the growth of the economy.
Determining Barriers
In the Roggenkamp and White (1998) qualitative study, the results from data collection suggested that entrepreneurs do experience obstacles that impact successful outcomes. While the ability to conquer barriers is possible for the entrepreneur, there is energy that must be expended to be successful. Behaviors or situations that lead to entrepreneurship failures are often related to a lack of education related to business procedures and function. Roggenkamp and White concluded that the chief obstacle to entrepreneurial success is the lack of business expertise. Even though the ability to work through challenges is possible, there is energy and time that must be exerted to come to some type of resolution (Roggenkamp & White, 1998). When there is a lack of adequate resources to sustain a business, failure is usually eminent (Boone & Kurtz, 1990). The entrepreneurs’ ability to grasp the business insight and expertise, will determine the success or failure of the venture (Hisrich & Peters, 1992; Schiffmn, 1998). Additional research that explores the successes and failures of entrepreneurs would provide valuable insight into the experiences of the entrepreneur.
Elango and partners’ (2007) qualitative research study addressed some of the barriers that are obvious with nursing entrepreneurship. Determining what prevents or
37 hinders nurses from engaging in entrepreneurial efforts in the U.S. was the purpose of the research study. Advantages of entrepreneurial nursing impact the quality of nurse practice, offer flexibility with time commitment, provide autonomy, and enhance patient care, which falls in line with the purpose of Elango and associates’ study. Bhave’s theory of entrepreneurial creation was used as the theoretical framework for the study, which has been proven and well known in literature related to entrepreneurship (Elango et al.,
2007). Easily tailored to entrepreneurial ventures, Bhave’s model is related to three states in venture creations: recognition of an opportunity, conquering barriers associated with entry, and competency with operations. Two focus groups were used. One group included 2 hospital administrators and 2 entrepreneurs, 1 from nursing and 1 from ophthalmology, and a nursing school dean. The other focus group included 20 students.
The data collected resulted in findings that identified barriers, which included lack of knowledge related to legal issues concerning business operations, lack of management expertise, and the lack of familiarity by consumers. Elango and colleagues concluded that study results were encouraging, such that nurse practitioners acknowledged the possible opportunities as an entrepreneur. Even though the challenges were considered significant, Elango and associates believed they could be conquered. Determining the impact of barriers when pursuing entrepreneurial ventures can be realized with further research.
Sankelo and Akerblad (2009) performed a questionnaire survey design study among
335 social care entrepreneurs of various educational degrees. The purpose of the study was to characterize the happiness and security at work of nurse entrepreneurs and owner- managers of social care companies in Finland while addressing the gap in the literature
38 related to how entrepreneurs deal with situations while at work (Sankelo & Akerblad,
2009). Questionnaires were mailed to the owners of social care organizations referred to as entrepreneurs, which totaled 765. Of those questionnaires, 18 were returned as undeliverable, 3 companies were closed, and an association, rather than private entrepreneurship owned 8. There were 338 completed surveys, rejecting 3 for incompleteness. There were 335 accepted responses. The sample size was further narrowed to 96, which represented those who had a registered nurse degree, and again to
84 representing owner-managers with employees. Data collection revealed that the majority of the participants reported a feeling of fulfillment with being an entrepreneur.
Sankelo and Akerblad reported findings, which indicated that a training program for the nurse entrepreneur is essential, but noted that there was little research to address the impact of training on the transitioning role. The data, which was analyzed with the use of the SPSS statistical software, revealed that coping strategies were greater after starting a business. Sankelo and Akerblad were able to conclude that there was contentment with their happiness while at work. Yet, there were things, which could be addressed to allow for an even greater well being for those who had to deal with coping. Roggenkamp and
White (1998) confirmed that with the absence of business skills and training, and lack of time to develop those skills, successful entrepreneurship, could be restrictive. Even though colleges offer courses and programs in entrepreneurship, Roggenkamp and White
(1998), and Wall (2013) noted that the traditional nurse education programs do not prepare entrepreneurs for the role. Including courses that provide the basics for nurse- owned businesses within the nursing curricula would help in providing knowledge related to non-traditional nursing careers (Roggenkamp & White, 1998). There is a gap between
39 nursing’s basic education and the necessary knowledge necessary for nurse entrepreneurs and independent practice (Wall, 2013). Robinson (2008) confirmed the knowledge gap, noting that there is a lack of support required for contract development and creating business plans. Competency is needed for successful self-employment that comes with time and practice (Dale, Drews, Hildebrandt, & Tielsch-Goddard, 2013; Fisher, Maritz,
& Lobo, 2014).
Faugier (2005) pointed out that because of the gendered nature of nursing, entrepreneurship was not a typical representation of the profession. A concerted effort that aims to establish systems that encourage innovation, inquiry, and risk is critical to promoting entrepreneurial efforts (Faugier, 2005). While nurses must be positioned to seize entrepreneurial opportunities, the nursing workforce has been described as having confusing and difficult situations (White & Begun, 1998).
There is a lack of effective entrepreneurial resources and support, which suggests that legal nurse consulting networking resources is limited (Summers, 2005). Research that describes the transitional process to practice independence is scarce. Caffrey (2005) asserted that little support exists from legal nurse consultant colleagues. Wilson and associates (2003) confirmed that poor nurse professional attitudes exist as a barrier to a successful transition to self-employment. Faugier (2005) noted that entrepreneurship for nurses represented a dismal picture, noting that the profession has not been seen as entrepreneurial, yet it is an opportunity to increase available career choices. Recognizing the changing aspects of independent nurse practice is of significance as a result of the increased stress placed on those who provide health care.
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Self-Efficacy Theory
The tenets of Bandura’s self-efficacy theory consist of the belief that individuals possess the capabilities for self-reflection (Bandura, 2004). With the determination of meaning associated with personal experiences as a consequence of self-reflection, individuals can explore perceptions and participate in self-evaluation, and ultimately change behaviors or thought processes (Bandura, 2004). Self-efficacy principles offer the basis and support for inspiration and personal achievement (Bandura, 1977).
Theory development pertains to the investigation and creation of proposals related to data associations and developing proposals into theoretical patterns. Alvarez
(2005) believed that the creation of an entrepreneurial theory continues to be a problem, with no general acknowledged or recognized theory in spite of efforts by researchers.
However, existing entrepreneurial theories have focused on: the discovery theory of opportunity recognition, the creation theory, which center on individual entrepreneurs, and the theory which refers to the framework in which entrepreneurs operate, known as the decision-making theory (Alvarez, 2005). Presuming that opportunities for entrepreneurs are created instead of through discovery may include suggestions for entrepreneurial accomplishments (Alvarez & Barney, 2007). Entrepreneurs generate opportunity.
Bandura’s self-efficacy theory aligns with the focus and intent of entrepreneurial goals and objectives, in addition to the determination and persistence in the pursuit of those goals. Stajkovic and Luthans (1998) discussed a social cognitive context that connects the elements for career growth entailing career interest, career choice, and occupation pursuit. Stajkovic and Luthans also provided an opinion and meta-analysis,
41 which suggested that 28% of improvement occurring with task performance is related to an individual’s level of confidence. When applying the self-efficacy theory to work performance, managers are convinced that effective performance is related to heightened self-efficacy. Self-efficacy is a major force for developing and following through with career aspirations (Stajkovic & Luthans, 1998). Completion of tasks met with resistance and conflict requires self-confidence and diligence. Consequently, the lack of self- efficacy hinders moving forward with a successful entrepreneurial business. Bandura
(1994) believed that principles of self-reflection were entangled within the beliefs associated with self-efficacy and the capabilities to accomplish tasks. Boyd and Vozikis
(1994) believed that self-efficacy described an individual’s faith in the ability for task completion, and impacts the progression of intentions related to entrepreneurial ventures.
Positive relations are significant in developing confidence while building self- efficacy (Banks & Banks, 2000). However, according to Wigfield (1994), the only indicator for obtaining goals successfully is not solely self-efficacy. When specific skills are absent, such as competency and knowledge, task proficiency will not occur, even with elevated efficacy.
Luthans (2002) provided an additional theory related to self-efficacy, which described a more comprehensive idea related to subjective well-being. The subjective well-being is what an individual believes, although there is no truth associated with the belief. Feeling content is related to subjective well-being. Maurer, Wrenn, Pierce, Tross, and Collins (2003) had views comparable to Luthans’ perception, noting that the belief that a skill can be acquired or fostered is encouragement to develop those skills.
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Research implied that if individuals had belief in skill development, those skills could positively change to grow in self-efficacy (Maurer et al., 2003).
Two significant elements related to successful results are social encouragement and self-efficacy (Torres & Solberg, 2001). Advice and opinions that come from social influence is probably the most pervasive feedback that can be given related to competency and worth (Scholl, n.d.). In the absence of that support, self-efficacy becomes damaged or weakened and lead to unfilled and unnecessary outcomes (Phinney
& Haas, 2003).
Fernańdez-Ballesteros, Diez-Nicolas, Caprara, Barbaranelli, and Bandura (2002) performed research using the quantitative approach related to cooperative efficacy to find meaning related to socioeconomic status and the structure of individuals’ confidence and collective efficacy. The study’s purpose aligned with the belief that an individual’s self- efficacy impacts life’s alternatives, the level of persistence, and susceptibility to stressors
(Bandura, 1997). The study’s sample was 1,214 participants that represented Spanish regions, ranging in age from 18-91 years of age. Women represented 52 percent of the sample with 48 percent for men. The socio-economic ranking consisted of 19 percent for the high-ranking, 55 percent middle status, and 24 percent for the lower class.
Fernańdez-Ballesteros and colleagues reported that self-efficacy scales were used to measure a level of functional efficacy, consisting of perceived personal efficacy, individual social efficacy, and collective social efficacy. A mixed 4-way analysis of variance (ANOVA) was used to determine the influence of socio-demographic elements on efficacy (Fernańdez-Ballesteros et al., 2002). Meaningful key results related to perceived efficacy was generated from the ANOVA; F(2, 2062) 917.46, P < .0001, and
43 socioeconomic status F(2, 1031) 22.08; P < .0001 (Fernańdez-Ballesteros et al., 2002).
The findings provided a mechanism for understanding the complex makeup of beliefs consisting of personal and shared efficacy. There is variability in the strength associated with self-efficacy that is directly related to the purpose of change (Fernańdez-Ballesteros et al., 2002). Individuals have the capabilities to manage situations that have a personal impact. Fernańdez-Ballesteros and partners concluded that individuals could have an effect on positive results when personal efficacy creates optimal results. Baum and
Locke (2004) determined that with the entrepreneurship characteristics of self-efficacy, organizational growth could occur.
Literature Gap
The perspective of entrepreneurs taking on various roles has been depicted in the literature review. The entrepreneur can be situated in a home-based opportunity or not.
The literature review showed that legal nurse consultants are regarded as a useful benefit to the legal industry, providing an alternative career choice.
The continuous theme discovered in the literature review was that entrepreneurship is related to uncertainty and innovation (Herbert & Link, 2006). A gap in existing research on entrepreneurship for legal nurse consulting was discovered in the literature review (Sankelo & Akerblad, 2009). Studies that examined business challenges for the legal nurse consultant are devoid. Studies examining the experiences of legal nurse consultants as entrepreneurs, and the transitioning stages of development are deficit.
Even though a lack of recognition was identified as a barrier to entrepreneurship,
Drennan and colleagues (2007), Elango and associates (2007), Wall (2013), and Wilson and colleagues (2012) confirmed that limited research exists related to entrepreneurial
44 nursing. As such, Wilson and colleagues (2012) did not examine specific challenges that exist with the journey toward entrepreneurship for nurses.
The majority of literature and research studies reinforced the belief that entrepreneurship propels the growth of the economy; however, several essential questions are left unanswered (Sankelo & Akerblad, 2009; Wilson et al., 2012). Very little research was identified as to the appropriate approaches to resolve conflict and challenges that exist during the transition to the nurse entrepreneurial role as a legal nurse consultant.
Economic success, for the most part, was identified in the research. Many non-research articles illustrate the entrepreneurs’ journey. However, the entrepreneurs’ environment along with the networking and supportive relationships is not adequately portrayed in the research literature. Wilson and associates (2003) stressed the gap in discussions related to the inclusion of business topics, and the focus to assist with the increase of support for the nursing profession advancement. Shirey (2007) and Drennan and colleagues (2007), agreed that insufficient evidence-based literature exist related to the nurses in the entrepreneurial role. Research was devoid of a candid representation and interpretation of the legal nurse consultant’s journey toward entrepreneurship. Because of the lack of sufficient data, additional research is needed that provides an accurate portrayal of the path toward entrepreneurship for the legal nurse consultant.
Conclusion
An awareness of the findings from Wilson and associates (2003) show that nurses with the appropriate chances can create organizations and function in entrepreneurial roles. While looking at the Elango and partner’s study and that of Wilson and colleagues
(2012), it is clear that nurses are lacking in the required knowledge to begin the process
45 toward business development. The lack of knowledge is related to the limited research available to those seeking entrepreneurial nursing opportunities. The review of literature reinforced the fact that entrepreneurship is risky and unreliable, yet, is needed to grow the economy while supporting globalization needs and the flexibility of organizations
(Morris, 2002). To seriously cultivate the entrepreneurial spirit for nursing, the educational opportunities for nurses must include the applicable knowledge to acquire the required skillset.
Summary
Chapter 2 provided a review of the literature related to the entrepreneurial journey and associated elements and influences. The research on current and historical literature gave contextual knowledge on entrepreneurship and the groundwork on which future research can develop. Gaining ideas and awareness about the significant aspects of entrepreneurship available in existing literature was the study’s focus. Entrepreneurship as a legal nurse consultant provides career opportunities outside the traditional nursing roles. The success of entrepreneurial efforts has adequately been studied. However, the difficulties, barriers, and successes experienced by entrepreneurial legal nurse consultants have not sufficiently been acknowledged or examined. Chapter 3 consists of the method and design for this study. The sample population, interview questions, reliability, and validity, appropriateness for the method, as well as the data analysis is covered in Chapter
3.
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Chapter 3: Method
Nursing research is critical to the change and progression of nursing practice
(Fowles, 2015). Research validates current knowledge and generates additional information while guiding and providing the basis for nursing practice (Kerr, 2015). The purpose of this qualitative exploratory case study was to explore the perceptions of legal nurse consultants regarding the journey to become entrepreneurs. The exchange of ideas that emerged from this study related to entrepreneurial experiences provided meaning for new and emerging legal nurse consultants. Conducting a qualitative exploratory case study helped to obtain an increased awareness of the perspectives of legal nurse consultants during the transition to entrepreneurship. Chapter 3 focuses on the study research methodology, the population, sample, informed consent, confidentiality, ethical and legal considerations, instrumentation, rigor, data collection procedure, and data analysis.
Research Method
Qualitative research is a method of scientific investigation and analysis designed to explore the experiences of individuals in personal situations or environments while acquiring a better understanding of the elements impacting those experiences (Gelling,
2015). Marshall and Rossman (2011) agreed that qualitative research is representative, explanatory, and grounded in the lived experience of people. The qualitative approach allows participants to have a voice (Pathak, Jena, & Kalra, 2013). The purpose of this study was to explore the perceptions of legal nurse consultants regarding the journey to become entrepreneurs. The qualitative approach was found to be appropriate in the quest to explore the different perspectives, which revealed the experience of legal nurse
47 consultants. A qualitative methodology served as an instrument to answer the research proposition as to whether successful entrepreneurial legal nurse consultants require a skillset that consist of clinical and legal expertise, and a sense of self-motivation and self- assurance.
A quantitative approach was not suitable for this study because the data that were collected could not be analyzed using statistical processes, techniques, or measured quantifications, which made the qualitative method the preferred research model (Pathak et al., 2013; Thomas & Magilvy, 2011). Qualitative research designs have flexibility and are open to related and background interpretation, rather than the quantitative research designs (Shank, 2006). Quantitative studies are reflective of manipulated variables and would not be appropriate for exploring personal experiences.
There are a variety of assumptions and approaches within the qualitative research approach. However, there are considerations and procedures that are evident when conducting qualitative research, which includes the assumptions that knowledge is subjective and that neutrality was maintained during the interactions with the participants related to the meaning of their lives (McEvoy, 2001). Qualitative research is defined as a group of case studies, individual experiences, interviews that reflect life stories, and observations, which explains difficult situations in individual lives.
With the exploration of the perception of legal nurse consultants regarding their journey to become entrepreneurs, the qualitative paradigm was used, as there was an opportunity for subjectivity while discovering what had not been seen or revealed before.
The use of comprehensive interviews through qualitative research methods, with no outside control as to the context, gave the study participants the ability to provide
48 unqualified assessments of the journey toward entrepreneurship (Baxter & Jack, 2008).
Nassaji (2015) agreed that there is no manipulation or influence as to context in the qualitative approach.
Research Design
Aslam, Georgiev, Mehta, and Kumar (2012) asserted that aligning the research question to an appropriate and applicable research design relevant to the research question capacity is necessary. The research design provided significance to the research method, research question, and data collection, using a structure to understand perspectives (Schram, 2006). A phenomenological study would have been appropriate if this was a study of the lived experience of a concept or phenomenon; however, this study used an exploratory single-case study design. Houghton and colleagues (2013) believed that a case study was an ideal approach to engage in a deep and intensive examination to obtain insight into an experience; such as the experiences of legal nurse consultants journeying to entrepreneurship. The case study approach provided the how and why of particular events and occurrences (Yin, 2003). Such questions in this case study aligned with the functioning associations required for discovery over time, instead of incidences
(Yin, 2014). The case study approach allows for a realistic investigation when there is not an obvious boundary between the phenomenon and context (Yin, 2014).
The case study design was appropriate for this study, as it provided an opportunity to obtain great insight into a case while permitting data collection from different sources.
This approach allowed for productive and contextual information to emerge from in- depth interpretations of entrepreneurial experiences. With the convergence of evidence in the case study approach, data triangulation assisted in strengthening the credibility of
49 the research findings (Baxter & Jack, 2008; Yin, 2014). Yin (1984) agreed that triangulation in case studies allow for the exploration of multiple sources of data. Data in this case study was collected using sources from in-depth participant interviews, Archival documents from the American Association of Legal Nurse Consultants, and researcher field notes. An opportunity for determining relevancy to real-life was possible with the case study approach. The explored case and unit of analysis is the legal nurse consultants’ journey to entrepreneurship.
The case study design has distinctive characteristics, which provides a linkage between empirical data to the research question, which leads to conclusions (Yin, 2014).
Data collection occurs amid identifying the research question and determining the conclusion. Linking data to a proposition is a characteristic of the case study design. The exploratory case study is appropriate when the identified case possesses the ability to provide a distinctive awareness as to the result of testing a theory or with the exploration of a phenomenon (Yin, 1984). Conducting this study with the use of in-depth interviews permitted the gathering of data from several participants that reflected on the experiences of the journey toward entrepreneurship. This exploratory case study focused on legal nurse consultants, which is a specific group of individuals. In the context of the legal community, legal nurse consultants act as trailblazers, which defy the status quo while modifying the nursing culture. This case study was bounded by context and definition.
Although the case study approach is only one of the qualitative approaches that attempt to understand the personal experiences, it was chosen based on the research question examining the perspectives and experiences of legal nurse consultants in the role of entrepreneurs. The inability to influence or control the participants’ behavior while
50 exploring contextual situations significant to the study phenomenon made the case study approach an appropriate design (Yin, 2003). Information in the nursing literature related to nurse entrepreneurs is limited. Identifying the different perspectives of the legal nurse consultant in independent practice is needed. There was an attempt to locate the general nature of the experience while gathering information from the collective accounts of entrepreneurial efforts. With the participants providing details of an experience, there was a suggestion as to the nature of that experience.
With the subjective attempt in qualitative studies, there are unavoidable preconceptions that can influence how data is collected (Tufford & Newman, 2012).
Bracketing is an approach to alleviate the possible harmful impact of prejudices that would flaw the research process (Tufford & Newman, 2012). Because of the closeness of the research topic, bracketing was an approach used to provide shelter from the collective effects of difficult or demanding information (Tufford & Newman, 2012).
Research Questions
The research question was developed as a plan to carry out the purpose of this study. The research question for this qualitative case study was:
RQ 1: How do legal nurse consultants describe their journey toward entrepreneurship?
The interview questions were used to direct the flow of the interview, follow-up, and prompts to encourage the study participants to share their knowledge and perspectives of legal nurse consulting during the transition to entrepreneurship.
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Population
The American Association of Legal Nurse Consultants (AALNC) has a membership totaling greater than 2000 members including 8 local chapters (Chapters,
2019). This study’s population was entrepreneurial registered nurses working in the
United States as legal nurse consultants. The initial participants were solicited by email after receiving written approval from one specific AALNC chapter to access the membership directory for research purposes. The use of the legal nurse consultant population holding membership in the AALNC allowed access to obtaining helpful data.
Broadening the participant recruitment occurred with the solicitation from additional
AALNC chapters.
Sample
Sandelowski (1995) reported that a study sample is a subgroup of the intended population. According to Gentles, Charles, Ploeg, and McKibbon (2015), a valid sample must be thought of carefully to ensure credibility in qualitative research. Participation in this study was voluntary. Purposeful sampling was used for recruiting the study participants. Purposive sampling is used when information is known about the population to make a decision when selecting the sample and size (Gentles et al., 2015).
Purposeful sampling involved having access to the participants who have membership in the AALNC, and who reside and work in the United States as an entrepreneurial legal nurse consultant. The AALNC membership was selected because of the accessibility.
Sandelowski (1995) suggested that the quality of data is the emphasis in qualitative research obtained from a participant or situation, as opposed to the size of the sample. Marshall and Rossman (2011) and Mason (2010) agreed that a sample size of
52 five to 25 in a qualitative case study design was ideal for obtaining data. Yin (2013) asserted that only a small number of participants would be possible in a study if the intent were to do an in-depth examination of the intended context. Relinquishing some of the value of the study would occur with an increase in the number of cases (Yin, 2013).
The initial potential participants were identified from a specific chapter of the
AALNC membership directory. A Southeastern state was initially chosen as the locality to obtain data because of the accessibility of the participants. Additional participants were recruited from the Northeastern and Midwestern states to reflect diversity within the sample. The sample size of this study consisted of 8 legal nurse consultants, who have practiced as an entrepreneur for at least 5 years. The small sample size of entrepreneurs was more focused and in-depth than a larger sample size, which is generally the case in quantitative methods. The participants were solicited by email and were asked to schedule an interview by either email or phone. All interviews were held via SKYPE™ at a mutually agreed upon time. The interviews continued until data saturation was reached. Alvesson and Sandberg (2011) deemed the sample to be fulfilled with the achievement of data saturation when no new information is added with additional interviews. Data saturation is reasonably achievable as each participant’s experience is different and complete data saturation is not likely. Qualitative studies have sample sizes that can be small as well as complete with the achievement of data saturation (Alvesson
& Sandberg, 2011).
LNC members of the selected chapters were solicited as participants, which consisted of 127 members. Seven members responded to the solicitation. Snowball sampling was used to ask participants to provide referrals. Streubert and Carpenter
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(2011) described how snowball sampling is a technique that uses one participant to recruit another participant. The participants were asked to identify others who were members of the study population and who met the inclusion criteria. There were 2 referrals identified from the snowball method, which were solicited by email. There was
1 response from the snowball method, which did not meet the inclusion criteria. The snowball sampling approach was terminated when data saturation was reached.
The participants did not have any commonalities related to workplace organizations, as they are self-employed, working in home offices independently of others. The participants who were asked to participate in the study have experienced entrepreneurship as a legal nurse consultant. The demographic data describing the study participants consisted of the gender, age, ethnic background, highest nursing degree, highest non-nursing degree, years of nursing experience, and years experience as a legal nurse consultant.
Inclusion and exclusion criteria. The inclusion criteria for this study consisted of participants that are licensed registered nurses practicing in the role of legal nurse consultants as entrepreneurs and were willing to be open about their journey toward entrepreneurship. LNCs who have practiced for at least 5 years as an entrepreneurial legal nurse consultant, and reside and work in the United States, was included.
Additional criteria for inclusion were participants having access to SKYPE™ via Internet capabilities. The exclusion criteria included legal nurse consultants with no entrepreneurial experience, registered nurses with no legal nurse consulting experience, and legal nurse consultants who do not practice as a registered nurse. Those legal nurses who have practiced less than 5-years as an entrepreneur will also be excluded.
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Ethical and Legal Considerations
Ethical considerations entail addressing trustworthiness and truthfulness, impartiality, thoroughness, privacy, reverence for intellectual property and colleagues, publications, nondiscrimination, and competency (Shamoo & Resnik, 2003). There is a duty to reveal any conflicts of interest to the study participants (Resnik, 2004). It is essential to be attentive to integrity to avoid bias, relative to findings, especially in qualitative research. Gelling (2015) asserted that it is important for others to have certainty in the research findings. Keeping and maintaining meticulous notes throughout the research process augmented this study’s trustworthiness (Roberts, Priest, & Traynor,
2006). Trustworthiness was endorsed through the positive exchanges with the participants. The trustworthiness of this qualitative case study research is embodied in the triangulation of the data analysis.
The selection of participants occurred after the University of Phoenix Institutional
Review Board (IRB) approval. No other organizational IRB approval was required, as the participants were not affiliated with any organization. Participation was voluntary.
Adinoff, Conley, Taylor, and Chezem (2013) confirmed that the credibility of research is dependent on the confirmability of data obtained from subjects without the threat of revealing information considered to be sensitive. The participants’ personal information was preserved through the use of alphanumeric identifiers. The audio-recorded interviews along with the corresponding interview transcriptions were safeguarded in password-protected electronic files. Access to the files is restricted.
Credibility. Credibility suggests the accuracy of the research data (Cope, 2014;
Shenton, 2004). The participants were observed for reactions when responding to
55 questions. Notations were made during the interview by the researcher to help with the interpretation of the information. Data from participant interviews were triangulated with the Archival documents from the American Association of Legal Nurse Consultants, an analysis of the transcribed data, and the theme matrix to determine credibility. The interviews were transcribed, including a word-for-word transcription, which was compared to the voice recordings for accuracy (Roberts et al., 2006). Transcription and coding of interviews as soon as possible increases data accuracy (Roberts et al., 2006).
Using line-by-line numbering within the interview transcriptions and records helped with inter-rater trustworthiness (Roberts et al., 2006).
To determine the strength of the research findings, different data sources were compared through triangulation to enhance data analysis. Data triangulation assisted with reducing preconceptions and bias while providing further contextual significance to the research results (Shenton, 2004). Detailed participant interviews were conducted by
SKYPE™ via Internet capabilities. During the participant interviews, the researcher notes documented the meaning of each interview, including body language, and expressive reactions to document the core of the interview. Abu-Ghori, Bodrick,
Hussain, and Rassool (2016) and Rose and Webb (1998) contended that researcher notes augment the description of study results, and are critical and analytic in nature, due to the immediacy of the documentation and subsequent perceptions. Data analysis of the transcribed data provided an explanation of the perspectives of legal nurse consultants during the transition to entrepreneurship while revealing themes and associations.
Dependability. The applicability of data steadiness over similar situations is associated with dependability (Cope, 2014; Shenton, 2004). Agreement by other
56 researchers supports this concept, addressing the soundness and constancy of the research findings (Cope, 2014). The dependability of data is necessary in qualitative studies. The use of the structured interview guide, while asking each participant the same questions helped to build dependability. Engaging in the research process supported the strength and character of dependability (Cope, 2014).
Confirmability. Confirmability signified that the perspectives of the legal nurse consultants were precisely represented without preconception. Confirmability strengthens validity. Roberts and colleagues (2006) asserted that the audio recording of interviews help to influence trustworthiness. The use of an audio recorder improved the accuracy of transcriptions. Keeping and maintaining meticulous notes throughout the research process, as well as the use of the computer-assisted qualitative data analysis
(CAQDAS) MAXQDA 12© software augmented accuracy of data from participant interviews and Archival Documents from the AALNC for cataloging and revealing themes, categories, and associations (Roberts et al., 2006). Data that embodies trustworthiness can be generalized to a wider population.
Transferability. Transferability is the decision as to whether the research results can be transferred to other populations (Cope, 2014). The experiences and perspectives of the entrepreneurial LNCs were explored in an unstructured environment.
Transferability is obvious when the study results show meaning to others not included in the study while associating those results to others’ experiences (Cope, 2014). However, generalizability capabilities might depend on the research intentions as to applicability to additional situations (Cope, 2014).
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Data Collection Procedure
Legal nurse consultants who hold membership in the selected chapter of the
American Association of Legal Nurse Consultants were recruited. Legal nurse consultants that met the inclusion criteria were contacted. The potential participants were solicited by email after receiving approval from the AALNC chapter to access the membership directory for research purposes. The participants were invited to schedule an interview time by either email or phone.
In compliance with HIPAA regulations, the participants’ information was safeguarded. The researcher developed the interview questions. The strategy for collecting data was the use of interviews conducted by SKYPE™ over the Internet or through the use of a dedicated telephone, using unstructured open-ended style questions.
Open-ended questions (Appendix A) allowed participants to express different perspectives and elicit in-depth responses. Response flexibility was possible with the unstructured questions, which would not have been likely with structured questions
(Palmerino, 1999).
The purpose of the interview and instructions were provided to the participants, with an opportunity to pose questions. The interviews were guided by a list of questions to ensure comprehensiveness and benefit from time limitations. The interviews were recorded when authorized by the study participant. The interview questions were asked in sequence, which consisted of progressing from one subject that provided the participants’ prompts in determining the flow of the interview. However, the sequence of questions was varied and determined by the participants’ readiness to discuss a specific topic. There was an expectation that all topics would be covered in some respect. Data
58 saturation occurred when it was obvious that data was duplicated, and when there were no new emerging themes.
Data collection for this study consisted of multiple sources of information, including participant interviews that included personal explanations and interpretations of the issues. Non-participant observations provided descriptive facts to assist with interpreting data obtained in the participant interviews. Archival documents from the
American Association of Legal Nurse Consultants (AALNC) provided a documented accounting of the legal nurse consultant and entrepreneurial role. AALNC documents provided information related to the characteristics of an LNC and independent practice.
Once collected, data were converged in the process of analysis instead of being managed separately (Baxter & Jack, 2008). Adding strength to the research findings will come with the different sources of data while supporting a better interpretation of the case
(Baxter & Jack, 2008).
Instrumentation. The researcher was the principal instrument. Xu and Storr
(2012) asserted that the development of knowledge comes from qualitative researchers being in the role of research instruments as data collectors and data interpreters.
Qualitative researchers must be comfortable and skilled with perceiving, witnessing, and obtaining information through interviews for data collection (Xu & Storr, 2012). The ability to be flexible is an important component of the researcher’s role as an instrument
(Xu & Storr, 2012). Researchers can react to unanticipated situations. The development of interview skills can occur with the researcher as an instrument while enhancing the strength and value of the information (Xu & Storr, 2012).
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Interviews using a consistent interview guide were the primary approach for data collection in this qualitative research study, as outlined in Appendix A. Audio recordings of the interviews were accomplished with the use of a SONY ICD-PX333 digital voice recorder. The audio recordings allowed for intense and valuable sources of data, which was explored following the interviews. While interviews provide the opportunity for quality data, there was control in shaping the interview plan, and the subjects had the control over what information was revealed (McEvoy, 2001). From a qualitative perspective, interviews produce knowledge that is seen as being shaped socially
(McEvoy, 2001). From an ethical standpoint, interviews are noninvasive, however, care must be taken to avoid harm (Sullivan, 1998). Practicing effective interviewing techniques, as well as establishing positive environments is critical to obtaining data.
A pilot study that consisted of three legal nurse consultant entrepreneurs was conducted prior to the full research implementation. The purpose of the pilot study was to assess the interviewing style, while determining the soundness of the interview guide for collection of the desired data, to address the research question. The pilot consisted of legal nurse consultants that were prominent in the legal community, and who met the study’s inclusion criteria. Pilot participants were contacted via email, which included a solicitation letter (Appendix B). The pilot participants were asked to sign the informed consent, which was the same as the study participants. The pilot participants were treated equally and fairly; the same as the study participants. There was an obligation to identify and safeguard the basic rights of the pilot participants and maintain confidentiality. The pilot participants indicated that no changes were necessary to the interview guide. The pilot study began after receiving the University of Phoenix Internal Review Board (IRB)
60 approval. Three legal nurse consultants (n 3) participated in the pilot, all three of them met the study’s inclusion criterion. The structure of the interview questions and protocol was retained after receiving feedback from the pilot study participants.
The interview questions were guided by the research question, which was designed to obtain a broad description of the journey toward entrepreneurship. The interview questions were developed and centered on the literature review noted in
Chapter 2, and the self-efficacy theory as the theoretical framework. There were precise questions related to the legal nurse consultant’s role and expectations as an entrepreneurial LNC. The interview questions were intended to determine the process toward the growth of an entrepreneurial LNC. There were follow-up questions that were intended to explain responses. Doody and Noonan (2013) found that as interview questions are posed, the prompting of additional questions provide an increased opportunity to enhance the meaning of the experience. Interview questions were intended to ascertain the perceived journey toward entrepreneurship. Interviews consisted of unrestricted open-ended questions that achieved comprehensive descriptions of the entrepreneur experience.
An interview guide (Appendix A) was created for data collection that included the interview questions:
1. How would you describe your role as an entrepreneurial legal nurse consultant?
2. What barriers and enablers did you experience on your journey to becoming an
entrepreneur?
3. What were your expectations as you developed your role as a legal nurse
consultant entrepreneur?
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4. How does belief and self-confidence play in the ability to be successful as an
entrepreneur?
5. What are some encouraging experiences related to your decision to become an
entrepreneur?
6. What advice would you give to another legal nurse consultant interested in
becoming an entrepreneur?
7. Thinking about your experience becoming an entrepreneur, are there any other
things you think may benefit other entrepreneurs or those aspiring to become
entrepreneurs?
Interviews took approximately 15-35 minutes in duration. Interview questions were relevant to the research question and were open-ended to encourage responses that were not structured. Interviews were conducted by SKYPE™ via Internet capabilities, which were audio-recorded with approval from the participants and transcribed immediately after each interview. Identifying information was removed to maintain confidentiality.
Prior to implementing the research protocol, a pilot study was conducted to check for strength and soundness of the instrumentation. Three experts in the legal nurse consultant industry who know the study population and research topic participated in the pilot study. Feedback was requested from the experts as to the appropriateness of the interview questions to determine if the questions elicited information responsive to the research focus. The experts were used to ensure that the questions were not reflective of vagueness or bias, and were not repetitive.
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Informed Consent. Prior to conducting research, obtaining informed consent from participants is essential. Pranati (2010) offered a reminder that informed consent is a directive for clinical trials. The nature and scope of the research study provided the participant with detailed information related to the study’s intent. Human subjects of research studies should be informed of the aspects of the study, with documentation as to a thorough understanding of the study characteristics by the subjects and agreement to participate (Pranati, 2010). Being candid during the informed consent process, helped with reassuring participants about confidentiality, and developing a comfort level with the participants.
An informed consent was provided to each participant before the start of the interview to review and sign (Appendix C). The intent of the informed consent was discussed with the participants preceding each interview. The essential ethical dimensions of measurement activities included in the informed consent included the participant’s ability to refuse participation in the study. The informed consent also included the choice to withdraw from the study without concern of antagonistic consequences, discretion, confidentiality, privacy, and safety from injury (Waltz,
Strickland, & Lenz, 2010). Participants should be made aware of procedures that do not require the participant’s active involvement, such as, observations, or covert tape recordings (Waltz et al., 2010). Those types of activities would invalidate the participant’s ability to control the revealed data (Waltz et al., 2010).
Even though there is no way to eliminate all possible risks, there should be an evaluation of potential risks, and the participants must be advised of all known risks
(Waltz et al., 2010). An effort must be made to reduce or remove risks while making the
63 most of the benefits (Waltz et al., 2010). The participants were not members of any group that constituted a vulnerable population, such as minors (Yin, 2014). When commencing the measurement activities, keeping the participant safe is a basic respect and courtesy (Waltz et al., 2010). The consent forms are stored in a secured filing cabinet, which will be shredded at the end of 3 years.
Confidentiality. Ethical issues in measurement are essential, especially with the swift fluctuations that are occurring with the use of technology in the health care system.
Those ethical concerns coupled with the integration of the Internet for collecting data and implementation of privacy protections are mandated by the Health Insurance Portability and Accountability Act. Ethical principles provide the foundation for the guidelines, recommendations, and standards designed to provide for the rights and well being of human subjects in measurement and research. Considerations were made for the respect for persons, which included informed consent, and which gave participants a choice as to participation based on information related to the study, the measurement process, and data management. There was compliance with beneficence, which entailed adhering to a duty not to harm while minimizing any risks related to the measurement process, and management of the storage of data. The participants were treated equally and fairly, especially related to the selection of participants. Researchers are obligated to identify and safeguard the basic rights of the study participants in relation to the basic ethical principles (Waltz et al., 2010).
Providing specific procedures to preserve confidentiality is necessary for subject participants. Confidentiality is critical during the interview process, observation, and when presenting the research (Corbin & Strauss, 2008). Anonymity was maintained by
64 omitting names and other identifiable information during the research process. To maintain the participants’ anonymity, a code was assigned to each participant. The participants’ anonymity and confidentiality will be maintained in any publication of the research findings. The data files are being stored in secured files for the duration of 3 years, at which time the materials will be destroyed. The researcher notes will be shredded in a paper shredder. Data from the audio recordings was downloaded from the hand-held digital recorder to the researcher’s personal computer, which was safeguarded in password-protected electronic files. The audio recordings and Archival Documents from the AALNC were then imported into the password enabled MAXQDA 12©, the computer-assisted qualitative data analysis (CAQDAS) software. The audio recording and electronic records were encrypted on a password-protected hard drive.
Rigor. Scientific rigor is paramount as to the value of research outcomes. With respect to qualitative research, rigor is associated with being open, conscientious and compliant with a philosophical view, and thoroughness with data collection and theory development (Baillie, 2015). The evaluation of qualitative rigor is based on the reasoning of the developing theory and the transparency related to the phenomenon of study (Baillie, 2015). Bracketing was used to provide an open context and not allow the intrusion of preconceived opinions. The results were an effective representation of the research experience. Developing trustworthiness in qualitative research entails the inclusion of the criteria of credibility, dependability, confirmability, and transferability
(Cope, 2014). Trustworthiness is a critical element of qualitative research. Shenton
(2004) described trustworthiness in the qualitative approach as supporting a naturalistic approach that correlates to reliability and validity. Roberts and associates (2006)
65 confirmed that the believability and authenticity of research comes from the strength of the research. An effective implementation method to ensure data and results are valid is essential.
Data Analysis
Data analysis began after the first interview, which included a synthesis of the information so underlying theories and relationships could emerge (Baillie, 2015).
According to Yin (2014), data analysis encompasses an evaluation, categorization, arranging, and analyzing, and reorganizing data to obtain findings. The unit of analysis that was explored was the legal nurse consultants’ journey to entrepreneurship. The responses provided data from legal nurse consultants’ perspectives on the journey toward entrepreneurship. The participants responded to open-ended questions that motivated comprehensive descriptions of the entrepreneur experience. Each participant denoted a separate and distinct unit of analysis (Yin, 2014).
Data triangulation is a technique used to strengthen the study’s credibility (Fielding,
2012). Data triangulation in this research study included participant interviews, an analysis of the transcribed interviews, a theme matrix, and the researcher field notes. The
Archival documents from the American Association of Legal Nurse Consultants were also used in data triangulation, which provided corroboration of the LNC role, and the opportunities for an entrepreneurial practice. The participant interviews were audio- recorded, and then transcribed by the researcher. Field notes were transcribed and were available to refer to during data analysis. Field notes helped recall interviews. Archival documents from the American Association of Legal Nurse Consultants provided data as to the experience, determination, and resilience required for success for the
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entrepreneurial LNC. Illustration of triangulation is shown in Figure 1. Using multiple
data sources in the case study design, a mechanism to articulate an expansive scope of the
issues validated the researched phenomenon (Yin, 2014). With the convergence of
evidence, the credibility of the research findings was strengthened (Baxter & Jack, 2008;
Yin, 2014).
Figure 1. Triangulation of data used to enhance credibility
Data analysis for this exploratory case study approach was to answer the guiding research question as an outcome of the study results. The purpose of this case study was to explore the perceptions of legal nurse consultants regarding the journey to become entrepreneurs. The proposition for this research study is: successful entrepreneurial legal nurse consultants require a skillset that consist of clinical and legal expertise, and a sense of self-motivation and self-assurance. The interview questions guided the research and
67 assisted in data collection from the study participants. Determining the study results occurred after evaluating the data.
After each audio-recorded interview, the researcher listened to the recorded interviews repeatedly and prepared a word for word transcription. Confirmation of the transcript accuracy occurred by reviewing the completed transcript while repeatedly listening to the audio recordings and reviewing the field notes. Bracketing provided the researcher with an opportunity to clarify the participants’ experiences and put aside any prior knowledge related to the entrepreneurial LNC to acknowledge the participants’ personal views and preconceptions (Tufford & Newman, 2012). The researcher was willing to pay attention and be receptive to the different viewpoints and perceptions during data collection.
The audio records, Archival documents from the American Association of Legal
Nurse Consultants, and the researcher’s field notes were imported into the password enabled MAXQDA 12©, the computer-assisted qualitative data analysis (CAQDAS) software. The MAXQDA 12© software is a computer assistive tool used for organizing data for analysis in qualitative research. The MAXQDA 12© was used for cataloging and revealing themes, categories, and associations. Codes were entered into MAXQDA
12© software for organization and categorization of the data, which created significant patterns and themes. The software has the ability to help with visualizing the data through the illustration of the perceptions and ideas. Reports can also be generated from the data. The researcher analyzed the data for common attributes and emerging themes.
The pattern-matching technique for analysis was used with this case study, which was found to be a valuable approach by Yin (2014). Pattern-matching is formulated in
68 case studies as a grouping of events, communicative activities, or the result of interventions, which are evident in the data (Yin, 2014). Ro (2013) used a pattern- matching approach in a case study to explore the reasons associated with the second- language reading of adult learners. Pattern-matching techniques were used to analyze data in the qualitative research of McCormack, Rock, Swanson, Burton, and Massolo
(2014), related to the demonstration of physical activity in urban parks.
In this study, the pattern-matching and coding technique helped to provide direction to the data analysis process. With pattern-matching, the LNC responses, Archival documents from AALNC, and researcher field notes were associated with the codes based on the theoretical framework. Codes were entered into MAXQDA 12© for organization and categorization of data. Patterns and formulations were established from the software, which correlated with the theoretical framework. When patterns have been identified in the data, themes, groups, and impressions are created from data coding
(Gale, Heath, Cameron, Rashid, & Redwood, 2013). Data can be split into parts for analysis for the ease of data management with the use of coding (Peng, Jianwei, Hsien-
Ming, & Lina, 2012). Coding patterns for data obtained from interviews is an efficient approach with interview transcription (Campbell, Quincy, Osserman, & Pedersen, 2013).
Saldana (2013) defined the coding techniques of: (a) initial (open) coding, (b) axial coding, and (c) theoretical (selective) coding. According to Saldana, organization, and clarification of the data is possible with coding. Coding assisted with the classification of the data for comparison while representing the interpretation of passages.
The first set of coding that was used in this study entailed the initial coding. Saldana
(2013) believed that the path for research development and subsequent study would come
69 from the initial coding. Suggestions from Saldana included reducing large volumes of data into smaller and separate parts during the initial coding. Initial coding occurred during the phase when data is related to the research question while identifying patterns, and finding groups of recurring data for categorizing (Saldana, 2013).
Axial coding allows for the development of the analysis, which is performed during the initial coding (Kikooma, 2010). An evolving approach helps to consider evidence equally, uncover analytic findings, and eliminate alternative interpretations (Saldana,
2013). Saldana (2013 noted that the discovery of characteristics and properties occur with the association of groups and subgroups.
Saldana (2013) described theoretical coding as a process that occurs during the second stage of coding. Saldana noted that all previously classified groups and codes were incorporated within theoretical coding, which helped to guide emerging themes.
Identifying potential relationships between categories is representative of theoretical coding (Saldana, 2013). Following the discovery of themes, an alignment with the central research question was determined.
Concepts evolved into themes. The themes were organized and grouped to examine the perceptions of legal nurse consultants regarding the journey to become entrepreneurs.
Well-defined associations between categories assisted with discovering valuable information (Turris, 2009). Sinkovics and Alfoldi (2012) noted that computer-assisted tools enhance the trustworthiness of research. Yin (2014) agreed that data analysis software is effective in coding and organizing large amounts of narrative data obtained from interviews. The frequency of words and patterns identified by MAXQDA 12© allowed for comparison and distinction of data to point out the relationships and
70 dissimilarities. The occurrence of patterns of propositions representing exact wording or synonyms was computed.
Summary
Chapter 3 incorporated the research method, research design, and validation for use. There are research goals and objectives for collecting data that suggested the use of research methods. When a researcher determines the intent of a study through the research question and whether or not to have the ability to control the context of a study, the choice for the research method is made. A clear purpose should reflect the objective toward acquiring data, whether gathering information from data points, as in the quantitative approach, or the qualitative approach, which consists of getting a thorough understanding of a particular problem from participants. When there has been a decision to conduct a qualitative study, an acknowledgment is made that an influence for context will not be reflected in the study.
Using a sampling size comprised of members of an organization helped in gaining useful information. Obtaining informed consent from those participants was necessary while preserving the confidentiality as an expectation. As researchers perform in the role of a research instrument, data collection can occur, consisting of taking and retaining detailed notes. When information is obtained, effective data analysis will be critical to addressing the research questions. This exploratory case study research design provided an opportunity to obtain meaning and understanding of the shared experiences of individuals allowing common themes to be discovered. Chapter 4 provides the study results, data analysis, and data collecting process.
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Chapter 4: Results
The purpose of this exploratory case study was to explore the perceptions of legal nurse consultants (LNC) regarding the journey to become entrepreneurs. Pinpointing a precise and detailed path or guide for emerging nurse entrepreneurs toward independence will provide knowledge to propel nurses toward success. Exploring the personal experiences of legal nurse consultants will provide an interpretation of what an entrepreneur encounters. An awareness of the required skill set for being a successful
LNC provides a unique perspective into entrepreneurship and provides an interpretation of what an entrepreneur encounters. The proposition for this research study is: successful entrepreneurial legal nurse consultants require a skillset that consist of clinical and legal expertise, and a sense of self-motivation and self-assurance.
Before the start of data collection, a pilot study was conducted to assess the interview style, while determining the soundness of the interview guide for the collection of the desired data to address the research question. The pilot was comprised of three
(n 3) legal nurse consultants that were prominent in the legal community and who met the study’s inclusion criteria. Following the pilot and feedback from participants, the structure of the interview questions and protocol was retained. Pilot participants did not believe any modifications were required.
The study participants included a sample of eight (n 8) legal nurse consultants, interviewed using open-ended questions. The interviews took place via SKYPE™.
Different data sources were collected and analyzed, which included participant interviews, an analysis of the transcribed interviews, a theme matrix, the researcher field notes and the Archival documents from the American Association of Legal Nurse
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Consultants. Chapter 4 discusses the pilot study, participant recruitment, data collection, demographic data, procedures for data analysis, and the themes that arose from the data.
Pilot Study
A pilot study was conducted to determine the completeness of the data collection protocol and interview guide for the purpose of collecting data to address the research question. A field test was not performed, as it was not indicated in this study. However, the pilot was a chance to receive feedback related to the interview guide and the interviewing methods. The pilot study provided the opportunity to ensure a smooth process occurred during data collection and make necessary adjustments to the interview procedure if needed.
The pilot study began after receiving the University of Phoenix Internal Review
Board (IRB) approval. Three legal nurse consultants (n 3) participated in the pilot, and all three of them met the study’s inclusion criterion. The pilot participants’ demographics are noted in Table 2. The pilot study participants reviewed and signed the informed consent form prior to starting the interviews, and were given an opportunity to ask questions related to any aspect of this study. The pilot study participants did not believe modifications of the interview questions or protocol was required. The interview guide and interview process stayed as originally structured.
Table 2
Pilot Study Participants Demographics
ID Age Gender Ethnicity Highest Nursing Highest Non Years Experience as Years Degree nursing Legal Nurse Experience as Degree Consultant Entrepreneur PS1 65 Female Caucasian Bachelor’s Degree in PhD 16 years 16 years Nursing PS2 68 Female Caucasian Master’s Degree in None 30 years 30 years Nursing PS3 63 Female Caucasian Associate Degree in None 20 years 20 years Nursing
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Sample Size
A purposive sampling method was used for recruiting the study participants.
Approval was obtained from the AALNC to access the membership directory for research purposes. The sampling procedure entailed soliciting members from the selected chapter of the American Association of Legal Nurse Consultants. There were 2 referrals identified from the snowball method. There was 1 response from the snowball method, which did not meet the inclusion criteria. The snowball sampling approach was terminated when data saturation was reached. Data saturation was obtained with the final participant when no additional information was gathered. While the study proposal estimated interviews with 10 entrepreneurial legal nurse consultants would be required, data saturation was achieved with eight interviews. This study’s sampling was concluded when phrases between the participants paralleled while describing the perspectives of entrepreneurial legal nurse consulting. Data saturation occurred when it was obvious that data was duplicating.
Data Collection
Solicitation emails were sent to twenty (n 26) legal nurse consultants, with an invitation to participate in the study (Appendix B). Eight LNCs agreed to be study participants. The study participants scheduled interviews via email. An informed consent was provided to each participant before the start of the interview to review and sign (Appendix C). The consent forms were filed in a locked file cabinet in the researcher’s home office after each interview.
Each participant was provided an opportunity to ask questions prior to the start of the interview. Interviews were conducted via SKYPE™; however, there were no video
74 recordings. The interviews consisted of seven open-ended questions (Appendix A). The interviews were audio-recorded with the use of a hand-held digital recorder. Although the length of the interviews was anticipated to last approximately one hour, in reality, the interviews averaged 15-35 minutes. To ensure confidentiality, each participant was assigned an alphanumeric identifier, which coincided with the order of the interview. P1 coincided with the study participant, which was interviewed first. P2 represented the second interviewed participant. Following the interview, the participants were asked for referrals that met the inclusion criteria thereby implementing a snowball sampling technique to increase the pool of potential participants.
A solicitation email was forwarded to the referrals (Appendix B). No additional interviews were obtained from the referrals. Additional referrals were not required as the interview responses from the 8 participants were found to be repetitive suggesting data saturation had been achieved.
The researcher listened to the audio-recorded interviews repeatedly to create a verbatim transcription after each interview. A review of the completed transcript occurred while listening repeatedly to the audio recording, to confirm the accuracy of the transcription. Common characteristics across the collected data were classified as themes. Significant words and expressions were identified.
Interview Results
The purpose of this qualitative exploratory case study was to explore the perceptions of legal nurse consultants regarding the journey to become entrepreneurs.
The interview questions were suggestive of the reviewed literature found in Chapter 2.
The interview guide sought to address the research question by guiding entrepreneurial
75 legal nurse consultants in describing their journey toward entrepreneurship. However, the discussions were allowed to progress naturally.
Demographic Information of the Participants
Demographic data was collected to describe the study participants, which included age, gender, ethnicity, highest nursing degree, highest non-nursing degree, years experience as a legal nurse consultant, and years of experience as an entrepreneur.
Demographic data is illustrated in Table 3. The participants’ nursing educational background ranged from an Associates of Science in nursing degree to a Master of
Science in nursing degree. The participants had at least 5 years of experience as a legal nurse consultant, with a range of 5-30 years of entrepreneurial experience. All study participants were female and reside in the Southeastern, Northeastern and Midwestern states. The ages ranged from 46 to 68. There were 3 African American and 5 Caucasian.
Table 3
Study Participants Demographics
ID Age Gender Ethnicity Highest Nursing Highest Non Years Years Degree nursing Degree Experience as Experience as Legal Nurse Entrepreneur Consultant P1 68 Female Caucasian Bachelor’s Degree Masters Health 5 years 5 years in Nursing Administration P2 61 Female African Nurse Practitioner Bachelor of 17 years 17 years American Master’s Degree Science, in Nursing Community Health Education P3 62 Female Caucasian Associate Degree None 30 years 30 years in Nursing P4 46 Female African Bachelor’s Degree Masters in Business 5 years 16 years American in Nursing Administration P5 51 Female Caucasian Master’s Degree None 5 years 5 years in Nursing P6 61 Female African Bachelor’s Degree None 18 years 18 years American in Nursing P7 52 Female Caucasian Bachelor’s Degree None 18 years 18 years in Nursing P8 62 Female Caucasian Master’s Degree None 16 years 16 years in Nursing
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Research Findings
There was an alignment of the participant’s responses with the theoretical proposition and related to the theoretical framework through pattern-matching. The theoretical framework consisted of Albert Bandura’s theory of self-efficacy. The participant responses were formulated by MAXQDA 12© from the interviews, the
Archival document from the AALNC, and the researcher’s field notes. The Archival document is a publication of the American Association of Legal Nurse Consultants, which is considered the gold standard for legal nurse consulting, offering descriptions of the LNC role, the entrepreneurial LNC, and different practice settings. The Archival document consists of contributions by a team of legal nurse consultants who were instrumental in its creation. The responses from interviews that were recurring topics included: determination, confidence, ability to work independently, responsibility, challenging, work flexibility, need for financial solvency, need for peer support/mentorship, need for education, marketing, need to network, provide attorney support, need for diverse background, risk, and lack of support.
Data Analysis
Data from the audio recordings were downloaded from the hand-held digital audio recorder to the hard drive of the researcher’s personal computer, and then imported into MAXQDA 12©, the computer-assisted qualitative data analysis (CAQDAS) software. In preparation for data analysis of participant interviews, Archival documents from the AALNC, and researcher field notes, a review of the data was necessary to determine the process for coding associated with the study design and theoretical framework. MAXQDA 12© software assisted with organizing data from participant
77 interview transcripts, the Archival documents from the AALNC, and field notes for cataloging and revealing themes, categories, and associations. Codes were entered into
MAXQDA 12© software for organization and categorization of the data, which created significant patterns and themes.
Data triangulation in qualitative studies helps to corroborate the truthfulness of the findings. Triangulation supplies various methods to examine a phenomenon.
Triangulation data included participant interviews, researcher field notes, Archival documents from the American Association of Legal Nurse Consultants, an analysis of interview transcripts, and a theme matrix.
The pattern-matching and coding technique was used to guide the data analysis process and emerging themes. Coding helped with classifying the data for comparison, as well as a representation of passage interpretation. Large phrases were reduced as a consequence of the contextual coding. Pattern-matching was used to identify patterns.
The significance of acknowledging a theme was to explore the understanding of an occurrence or experience. Data were separated into parts for analysis with the use of coding because of the efficient approach with interview transcription. Characteristics were uncovered, which the participants associated with the situation or facts of their experiences. Concepts evolved into themes.
Data organization consisted of coding, which represented the text characterizing a descriptive idea. Open coding was conducted, which was the initial part of the analytical process. This initial coding helped with breaking apart the data. Categories started to develop while looking for similarities and differences. If the additional text aligned with
78 the current nodes, it was added onto the existing nodes. If the text had additional information, then a new node was created.
The next sequence of coding was axial coding, in which a refinement of the categories occurred. Merging of the codes occurred, to help manage the codes, which allowed for a ranked order of nodes, and which allowed the amount of free codes to be reduced. Connections between the categories were made. A constant comparison of the passages occurred, which led to coding, removing codes, and sometimes recoding the data, to improve the categories. Modifying the hierarchy of codes permitted a greater critical analysis of the data.
Identifying relationships between the categories represented theoretical coding.
Pattern-matching was used to define the entrepreneurial legal nurse consultants’ journey toward entrepreneurship and identify themes. Patterns were identified in the data, which allowed themes to be created from data coding. There was an identification of central classifications in which sub-categories could be applied. Following the discovery of themes and representation of the experiences of entrepreneurial legal nurse consultants, an alignment with the central research question was determined.
Interview Question One
How would you describe your role as an entrepreneurial legal nurse consultant?
All the participants described the role of the entrepreneurial legal nurse consultant (LNC) as an opportunity to work independently as a nurse. The participants provided information related to the complexities and challenges of the entrepreneurial journey. All the participants described the role of the legal nurse consultant as a link between medicine, nursing knowledge, and the law, which helps to create an understanding of
79 legal cases. While no formal LNC education is required, the entrepreneurial LNC role provides an opportunity for nurses to work independently, while reviewing and providing an analysis of medical records to attorneys to help with understanding medical issues. All the participants indicated that the opportunity to educate and assist with understanding the medical issues and standards of care was seen as a component of the legal nurse consultant’s role. P1, who retired from clinical practice with 5 years experience as an entrepreneurial LNC, provided the following explanation of the entrepreneurial LNC role:
I see my role as being able to add value to the legal case analysis by reviewing the
charts, giving clinical information and being able to educate and provide
information back to the client, so that they can understand the medical and
understand the standard of care related to the injury (P1).
P2 explained that her journey as an entrepreneurial LNC began 17 years ago but continues to work in the clinical area as a nurse practitioner. P2 explained her role as
“reviewing medical records for attorneys, and providing health and safety consultations and education related to standards”. With 30 years of entrepreneurial experience as an
LNC, P3 described the entrepreneurial LNC role as a difficult one.
P3 further defined her role as she journeyed toward an LNC entrepreneur as:
It takes so many aspects of nursing, your basic knowledge experience, not just
nursing experience, but living experience. It really portrays in-depth
communication skills, as far as the knowledge of the legal system, and the
nursing-medical system from a practicing clinical standpoint. Being an
entrepreneur in any aspect of any profession is a pressure on the individual to
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constantly maintain (I think) standards above what if you were just an employee.
There’s pressure to maintain your standards, maintain financial stability, and
provide yourself with insurance benefits. And the role, if you go into with less
experience, let’s say, 5 years, your area of expertise is going to be very limited
(P3).
Having earned a Masters degree in business administration, P4 reported starting her entrepreneurial journey 5 years ago. She remembered that knowing a lot of people was required to become an entrepreneur that necessitated having the right resources while understanding how to keep your clients.
P5 began her role as an entrepreneurial LNC 5 years ago, and aligned with P1, defining the role as, “assisting attorneys with their cases and help them decipher the medical records”. Working as an entrepreneur for 18 years, P6 felt it is important to know how to function alone. P6 further described the role as:
I see myself as a medical professional that helps the legal profession to
understand medically related issues that they are trying to review whenever there
is a legal issue that comes up between a patient and either a provider or a facility.
My job is 2-fold; I want to be sure that the facts of the case from a medical
perspective are explained to the attorney in a clear manner. I also want to be sure
that there is a clear understanding of what happened medically inside the case, so
there is no confusion about what really happened (P6).
The entrepreneur LNC role for P7 consisted of a “review of medical records and to answer questions from attorneys and insurance companies”. P8 considered herself an
81 expert in the legal field of medical-surgical nursing, reporting 16 years as an entrepreneur
LNC. P8 described her LNC role as:
Giving certificate of merit proving that it is a worthy case for the lawyers to move
forward. I will review the case, write a summary report or I will be deposed
depending on what state I am working in to give a deposition. Sometimes it goes
to court (P8).
Interview Question One Summary
The participants provided the essence of the entrepreneurial journey that highlighted the professional goals while performing tasks, representing the path toward efficiency, productivity, and growth. The participants defined the entrepreneurial LNC role as acting as experts in legal cases and helping with the understanding of medical terminology. The legal nurse consultant is instrumental in impacting the outcomes of legal cases.
Interview Question Two
What barriers and enablers did you experience on your journey to becoming an entrepreneur?
Barriers. Obtaining clients, financial solvency, and maintaining cash flow during the creation and growth of an entrepreneurial business, is always a concern for the participants. Throughout their entrepreneurial journey, P2, P3, and P4 found that effective marketing and on-time payment of invoices is often a barrier to continued success as an entrepreneur. The lack of a steady cash flow is seen as a roadblock and a hurdle when attempting to maintain a thriving entrepreneurial business.
P2 suggested that staying on top of billing is important, noting:
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One time I tried to bill somebody all at once and the guy was like, “whoa”. Had I
broken that bill up into threes, he would have paid it, and wouldn’t have
complained; I took a loss, but it was worth it to possibly get work with them again
(P2).
P3 discussed her journey barriers, noting:
It’s very hard to do marketing. Some people are very uncomfortable with that;
it’s basically door-to-door. You have to start out with the fees lower. They’re
getting more than what they are paying for. That’s how you get started, and I
think that’s frustrating (P3).
P4 also discussed challenges with maintaining financial soundness during the journey. P4 submitted an invoice after a case has settled, recalling, “After spending 15 hours on one project and submitting the invoice, the attorney advised that the case did not go through litigation”. P1 noted that she did not receive a lot of explanations as to what was required when she started on her entrepreneurial journey. P3 also discussed the isolative nature of entrepreneurship, noting:
The isolation is difficult for most people coming from the clinical setting. You
don’t get a lot of support within our area. Our legal nurse consulting entity has not
been very actively supporting us. But that’s part of the isolation; you get so
committed with your own practice that you forget about others (P3).
P5 discussed the difficulty of getting started as an entrepreneur, noting:
I think initially it was getting cases and getting started, and getting my name out
there; I am still working on that, you know for years. It was very slow at the
beginning. I worked full time in the hospital, and I still work part-time (P5).
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P6 remembered the learning curve needed to be successful. P6 discussed the difficulty learning to be careful with submitting the finished work product prior to compensation, noting:
Do not give information away all of your information before you get paid. I did
give information away early on to an attorney who did not pay me. As nurses, we
are more interested in helping and nurturing. We are not thinking from a business
perspective like these guys. The attorneys are trying to get what they can for as
little money output as then can (P6).
P7 described one of her biggest barriers was, “trying to get attorneys to understand what it is we do and why we do it”. P8 questioned her value as to the entrepreneurial role, having the perception; “I may have cheapened myself when I started because I didn’t think I was worthy of the job”.
Enablers. An extensive nursing background is not required for the LNC entrepreneurial role, but it does assist with developing the confidence level. Three of the participants (P1, P3, and P4) described the enabling factors during their journey was related to having a strong nursing background and networking with other legal nurse consultants. P1 shared that she had over 40 years of nursing, noting, “I had a lot of confidence that I could do what they were asking”. However, P1 noted that having other legal nurse consultants, as a resource is helpful, just to know if you are doing the job correctly. P3 agreed, noting that she felt having other nurses, as a resource was helpful, but noted, “I think going into the legal nursing role, you must have at least 10-15 years of nursing experience”. P3 further believed that you have to be able to “call another nurse and say, hey, this attorney said this, does this sound right”. P4 discussed the benefits of
84 networking with other LNCs: “Attending legal nurse consultant events where you meet other legal nurse consultants and share ideas and discuss some of the challenges that they’re having and kind of brainstorm”. An enabler for P2 was receiving encouraging feedback from attorneys. P5 discussed how getting support from different LNC groups helped her transition into the new role. P5 found that the J.E.R.K.s (Juris Educational
Resource Knowledge) were the main support, with AALNC also being helpful. “It was networking at the AALNC that led me to the J.E.R.K.s” (P5). P5 recalled how she would
“just read all their emails. I learned so much from that. They were there to bounce any question. They’re still there for me”. Receiving referrals and business tips from clients was encouraging for P6. P7 remembered the support she received from a mentor with the start of her entrepreneurial journey. P8 recalled the support she received from the
AALNC as she started on her entrepreneurial journey; remembering the “pep talks, which helped considerably”.
Interview Question Two Summary
The data suggested that the enablers and barriers experienced throughout the LNC entrepreneurial journey is related to the availability, or lack thereof of networking, and the support received from others in the same industry. The participants discussed the importance of collaboration with peers during their journey. The participants are aware that the business growth and the successful build of innovative ideas and opinions are most effective when interacting and exchanging those ideas with others. The values- driven approach is an element for a successful entrepreneurial journey.
Interview Question Three
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What were your expectations as you developed your role as a legal nurse consultant entrepreneur? Three participants believed that they would do well as an entrepreneur. P1 noted that she had no expectations, or preconceived ideas yet highlighted her over 40 years as a nurse. P2 noted that “the process was almost intuitive for me, and maybe it had to do with my previous background as a pharmaceutical rep. I feel like based on that experience, I knew something about business principles”.
As P3 reflected on her journey expectations, there was a certainty that entrepreneurship would be successful, noting,
“I did it because this was my area of expertise, and I had a lot of experience…I
was in a clinical setting, in a trauma area, a rehabilitation area for 20 years, I was
always reviewing cases for physicians and looking at past medical records…I had
the background…I wanted some flexibility in my schedule”.
Gaining new clients and a good return on an investment was the expectation for P4, noting: “You put a lot into it…I remember purchasing a lot of books and reading up…whether it’s time or finances, you expect a good return on your investment” (P4).
P5’s goal of getting more clients with an objective to either work PRN [as needed] at the hospital or quit all together aligned with P4’s expectation. P6 explained:
I did not have wild expectations that I was going to get wealthy doing this. The
major reason that I decided to do something like this is because I had a family…I
needed something that afforded me a lot more flexibility than showing up at the
hospital at 6:20 every morning. I knew that I had a knowledge base and skill set
that would allow me to practice in a way to still utilize my education and
expertise (P6).
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The expectations for P7 were related to the goal to be an independent consultant, knowing there would be a learning curve.
Interview Question Three Summary
As the participants considered venturing on an entrepreneurial journey, they knew they could make the transition to entrepreneurship as a legal nurse consultant based on past experiences and depth of their nursing knowledge. There were no high expectations, aside from knowing they were capable of doing the work, with the ability to control the work they accepted.
Interview Question Four
How does self-confidence play in the ability to be successful as an entrepreneur?
The participants believed that self-confidence was a significant indicator of quality performance. Reflecting on the entrepreneurial journey, P2 stated,
Those are crucial factors. You have to be able to present yourself well to your
clients. Particularly in the legal nurse consultant world, attorneys are intelligent,
sharp, judges of people. They want somebody who can take a position and stick
with it and not be dissuaded. I liken it to when nurses contact physicians about a
clinical situation; they have to be able to present their opinion, describe what’s
going on, stand firm and not be intimidated and get what they need for their
client, in this case, their patient. If you lack self-confidence it’s going to be a
much harder road as an entrepreneur and that would dissuade many people from
even attempting to start a business, because of that lack of confidence (P2).
P3 agreed,
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Without a doubt, even if it’s something you pump yourself up for before you go
into the office to meet with an attorney, and say, I can do this. I’m going to
visualize myself as being cool, confident, and presenting myself well. So,
confidence is definitely a factor.
P4 noted, “you have to have confidence in yourself to be able to speak your opinion, and be able to defend your opinion”. P4 associated self-confidence with how she was reared, noting, “it’s the way I was raised; I can be anything that I want to be, and do anything I want to do”. P5 described how “you have to be confident about your experience as a nurse…I had pretty good self-confidence in my experience and my abilities prior to even getting into it…a meek-type of personality doesn’t gel right with entrepreneurship”. P6 explained how her level of self-confidence and independence developed as a result of the position she held while working in a hospital. P6 further noted:
When I came outside of the hospital into legal nurse consulting, there wasn’t a
single attorney who could tell me they knew more than I did, because I know they
don’t. I have attorneys tell me, well, you know, I been doing this for years, so, I
understand. That’s probably the attorney that I’m probably not going to work for
because they’re probably going to argue about what they know more than I do.
The attorney that says I default to you because I don’t know what I’m reading, is
the one that I want to work with. That confidence leads you to a place where you
become a partner and an ally (P6).
P7 found that “you need to be almost over-confident, but yet know your limitations. P8 discussed how confidence was a characteristic needed to be an entrepreneur. “You have to go to court and you have to be able to speak to the jury” (P8).
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Interview Question Four Summary
Having self-confidence during the LNC entrepreneurial journey relates to knowing your capabilities for making the best decisions and being willing to take risks associated with becoming an entrepreneur. Being confident in decision-making and the ability to perform effectively is critical to being successful.
Interview Question Five
What are some encouraging experiences related to your decision to become an entrepreneur? P1, P2, and P3 discussed the importance of having a strong support system or mentors on their journey toward a successful entrepreneurship. P1 and P3 felt that their engagement with other legal nurse consultants as mentors was a significant element of encouragement in their journey. P1 was grateful for assistance received from another
LNC that she worked with, noting, “she developed outlines, and gave me a lot of samples”. P3 acknowledged that the opportunity to remain in the nursing field after retirement and recalled being encouraged to “reach a little higher”.
P1 also discussed the process that takes place during the development of the LNC entrepreneurial role:
It works great for me; I’m retired from active nursing, so this was something to
give me an opportunity to work from home and keep in the nursing field. It’s a
constant you know, able to learn new things. It’s a real growing experience. (P1)
P2 commented on feedback received from a client, noting, “I did a report for an attorney, and he commented that it was the best report he had ever received from a legal nurse consultant”. An attorney similarly encouraged P8 after testifying in a hospital case related to nursing documentation. P4 focused on the inner drive that propelled her during
89 her journey, noting, and “I think the passion to succeed and have a successful business drives you to continue to pursue”. P5 highlighted the need for having a personal drive, expressing that “It has to come from within to push yourself”. P6 has been encouraged by the relationships with attorneys that develop as a consequence of a successful case outcome.
Interview Question Five Summary
Although not readily available during the LNC entrepreneurial journey, the availability of mentorship was a hopeful expectation, knowing that mentoring helps to support successful outcomes. Several of the participants had similar experiences with other legal nurse consultants that mentored them during their entrepreneurial journey.
Receiving support and mentoring was thought to be instrumental for success as an entrepreneur. Having the determination to continue as an entrepreneur is a key component to success.
Interview Question Six
What advice would you give to another legal nurse consultant interested in becoming an entrepreneur? P2, P4, and P5 believed that having a support network of other entrepreneurial legal nurse consultants and resources were important advice for nurses interested in entrepreneurship. Understanding the legal industry was resonated by
P2, P3, P4, and P7. P1 felt that receiving feedback was important to determine if the client is getting the expected and intended work product. P2 shared an experience with another LNC starting a new business that needed coaching. “You’re not even sure what you know and what you don’t know” (P2).
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P2 believes it is important to be aware of your capabilities and strengths while having a plan in place:
There’s a lot of groundwork that needs to be done. You need to know what you
are going to sell. You need to have a business agreement or a fee schedule worked
out. You need to know who you are going to sell to; whose your target market. In
the case of a legal nurse consultant, do you want to work with plaintiff attorneys,
do you want to work with only defense attorneys, and do you want a mixture of
both (P2).
P3 discussed the importance of understanding the legal industry, noting that it was dissimilar to nursing. “Definitely network, network, network is the key” (P4). P4 also stated, “Understand the industry. In order to be successful, you certainly have to understand the challenges, the risks, how to keep clients, your pay structure”.
P5 also thought that reaching out to attorneys was important, “Whether it’s cold calls or postcards. I did a lot of postcards, and I would get like 2 or 3 cases out of maybe 80, which doesn’t sound like a lot, but it is if you maintain those relationships”. P6 always recommends those interested in becoming an LNC to visit the AALNC national website.
“You have to go to the organization that sets the standard. It is important to arm yourself with what it is you need to do; learn as much as you can about what it is you’re trying to do. Find somebody that will help you to establish the business in a way that helps you run it correctly” (P6). P7 believed the best advice is to “stay up on what legal nursing consulting is and how it is defined and how the industry’s looking at it”. P8 was adamant in recommending membership in the organization, noting, “I can not say enough about
91 how much they help in every step of the way. They’re a great networking place. I think we reach out to the young people and help them with their startups” (P8).
Interview Question Six Summary
The role of the entrepreneurial legal nurse consultant requires a network of other entrepreneurs to share ideas and challenges. Networking during the entrepreneurial journey is essential for fostering relationships. Understanding the value of those relationships will help when growing the business. The importance of knowing the intended audience was also echoed in the participants’ responses.
Interview Question Seven
Thinking about your experience becoming an entrepreneur, are there any other things you think may benefit other entrepreneurs or those aspiring to become entrepreneurs? The P2 and P3 felt that having a strong determination and being persistent during the entrepreneurial journey was important for those aspiring to be entrepreneurs. P1 discussed how important it was in understanding how to set up your business, “there’s tax information, you need to know what equipment; there’s a lot of things upfront that you need to put together. You tend to go overboard getting things and then find out that’s not something you’re going to use” (P1). P2 provided an analogy to the entrepreneurial LNC, noting:
The business world, the legal world - everything doesn’t operate like nursing. So,
you know you are getting ready to go to a different country that has different
rules, and different language, and different mores, and different way of being and
acting than nursing (P2)
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P2 also discussed the importance of knowing your worth and stressed, how new nurses have a tendency to undercharge, noting, “nurses have this issue with self-worth…don’t let anyone bully you”.
P3 felt that education was important for the aspiring entrepreneur:
Continue to educate yourself in such a way that you, first of all, know what you’re
doing, and that gives you confidence. I think to be persistent. Everyone’s path is
different; it doesn’t mean it’s better or worse. It just means that you need to obtain
the knowledge that you need by however means necessary to shine in terms of
what you do. P3 further stressed that LNC was important to nursing, noting, “In
every nursing program there should be a semester of legal nursing”. (P3).
P3 also noted, “If you go out on your own, you’re isolated. You don’t have that contact with anyone anymore. You have to be willing to do it all by yourself”. P8’s beliefs aligned with P3’s assertion that education was important. P8 explained the importance of attending conferences and taking advantage of nursing journals that often included articles with a legal focus.
Interview Question Seven Summary
Being unwavering during the journey toward entrepreneurship was obvious in the participants’ responses. Knowing self-worth as an entrepreneur is essential to making a place in the legal nurse consulting industry.
AALNC Documents
Documents from the American Association of Legal Nurse Consultants confirmed the roles of the LNC, and the opportunities available for those who strive to be in an independent entrepreneurial practice.
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Table 4
AALNC Data
LNC Role Successful LNC Entrepreneur LNC Support in medical- legal Work independently Work independently Litigation Bring health science Strong clinical Self-motivated, Self-confident, education and clinical experience, medical- assertive expertise skillset legal continuing education Collaboration with Need for analytical Need for marketing ability to attorneys skillset maintain client base Knowledge of litigation Possess financial resources and process business skills
Table 4 reflects AALNC data. These documents reinforced that the same foundation of the nursing process is evident in the problem-solving practice for the LNC. These documents confirmed the importance of the LNC in evaluating and providing opinions related to the delivery of health care in various medical-legal cases. The value of the LNC related to knowledge and clinical experience was highlighted. There is confirmation that success for the LNC in an entrepreneurial practice requires a strong ability to critically examine a variety of legal cases with a medical component. Success requires resilience and determination to operate a practice. Participating in continuing education opportunities helps with the success and enhancement of the LNC role. Marketing and developing the business is an important component of the entrepreneurial LNC. Having adequate financial resources will be essential for maintaining an independent practice.
The capability to function independently with the persistence and confidence to complete tasks are necessary skills for the entrepreneurial LNC. Being assertive and confident with the procedures necessary to set-up an office is necessary to sustain a successful business. This would be an appealing opportunity for those LNCs who are self-motivated with a self-confident disposition. Having the confidence to render
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opinions and recommendations for handling of the medical-legal cases is an element and
important function for the LNC.
Field Notes
The researcher’s field notes were coordinated with the participant interviews and
then transcribed. Field notes that included the participant dialogue were detailed as
referral data during the data analysis. Field notes were important to recall participant
interviews related to the research.
Themes
The research question that guided this qualitative case study was: How do legal
nurse consultants describe their journey toward entrepreneurship? Pattern-matching and
theme inquiry were used to determine the characteristics evident during the
entrepreneurial journey for legal nurse consultants. Themes emerged from the data as a
result of qualitative data analysis. The analysis included a review of the interview
transcripts, the audio recordings, researcher field notes, theme matrix, and Archival
documents from the American Association of Legal Nurse Consultants (AALNC)
documenting an accounting of the legal nurse consultant and entrepreneurial role.
Exploring the participant’s journey to entrepreneurship led to the following
emerging themes of confidence related to performance capabilities and determination to be successful. These prominent themes emerged during data analysis. With pattern- matching, the LNC reflections were associated with the theoretical propositions identified related to the theoretical framework. The themes that illustrate legal nurse consultants’ journey to entrepreneurship are depicted in Appendix D.
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Archival documents obtained from the American Association of Legal Nurse
Consultants and the researcher field notes were used to triangulate the data collected from the participant interviews. Analysis of data from the AALNC and the field notes were aligned with data obtained from the participant interviews. Data from the AALNC and field notes helped to validate the thematic outcomes.
Theme One: Determination to be Successful
Being a successful entrepreneurial legal nurse consultant requires dedication, perseverance, and persistence. An illustration of determination to be successful is illustrated in Figure 2. The desired entrepreneurial path does not always develop or progress as planned. Having the resolve and willpower to continue pushing forward in spite of obstacles is essential for establishing a thriving business. Stamina to maximize opportunities is required. Having the resolve and preparedness to complete tasks was noted in the AALNC secondary source.
The study participants consistently repeated the importance of receiving support from other nurse entrepreneurs for entrepreneurial success. Having the support of others who have already established successful businesses is needed for the emerging legal nurse consultant. Receiving the inspiration and guidance from others provides an encouraging path toward success past the learning curve.
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Validation of Themes
As themes develop, reflection is necessary for an awareness of what the data is
revealing. The prominent themes that emerged during data analysis included: confidence
related to performance capabilities and determination to be successful. In shaping the
themes, a repeated review of the data occurred to determine commonalities, consisting of
listening to the audio recording and repeated review of the transcripts, field notes, and
documents from the AALNC. The themes that characterize legal nurse consultants’
journey to entrepreneurship are depicted in Appendix D. The totality of the identified themes was evident in the participants. The research question was answered by the study findings. The research question queries, “How do legal nurse consultants describe their journey toward entrepreneurship?” It was apparent that an interrelatedness of themes is seen during the entrepreneurial journey.
Summary
There was one research question that guided the study’s data collection: How do
legal nurse consultants describe their journey toward entrepreneurship? This question
was explored through interviews with entrepreneurial legal nurse consultants. There
were variations in the participant responses. However, themes were revealed through
CAQDAS MAXQDA 12© common to several participants, which consisted of
confidence related to performance capabilities and determination to be successful. The
participants were transparent in their depiction of the entrepreneurship journey as an
LNC. The LNC was described as a vital contributor to the outcomes of legal cases. The
participants resonated that the level of success achieved during the entrepreneurship
journey is associated with networking and the support of others in the same industry.
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Determination was an additional element that impacted the outcome toward nurse entrepreneurship, which helped with the enjoyment of autonomy.
Chapter 5 offers a comprehensive discussion related to the perception of legal nurse consultants, regarding the journey to become entrepreneurs. It offers suggestions, conclusions, and recommendations related to the perceptions of entrepreneurial legal nurse consultants.
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Chapter 5
Conclusions and Recommendations
The purpose of this case study was to explore the perceptions of registered nurses on their journey to entrepreneurship while working as legal nurse consultants for five or more years. Exploring the different perspectives and experiences might increase understanding and knowledge related to the experience of the entrepreneurial legal nurse consultant.
Chapter 4 described the sample that participated in the study, a summary of the process for data collection, an evaluation of the pilot study, and study findings. Chapter 4 also discussed the prominent themes, which emerged from the study.
The research question that guided this study, was how do legal nurse consultants
describe their journey toward entrepreneurship? The prominent themes that emerged are
confidence related to performance capabilities and determination to be successful.
Chapter 5 includes a summary of the study, a review of the prominent themes, and
the influences of new knowledge, limitations, and conclusions. Discussions are centered
on findings from the study, including the study results, meanings, and recommendations
shaped from implications, and revelations.
Legal nurse consultants (LNCs) are the link between the legal and medical
communities (Milazzo, 2007). The overall findings suggested that the work can be
challenging, and the need for determination is unavoidable during the LNC
entrepreneurial journey. Despite this conclusion, the participants revealed an underlying
feeling of gratification and fulfillment and credited a valuable worth to the journey.
LNCs are very active during the litigation process, which includes reviewing and
101 analyzing voluminous medical records in various types of legal cases that describe patient care during health care events (Peterson & McMullen, 2007). LNCs often support attorneys and organizations in independent practice as entrepreneurs and can provide support to insurance companies, governmental agencies, and state boards of nursing
(Castellana, 2014). Nurse entrepreneurship encourages innovation, which influences change (Wilson et al., 2012). The path toward entrepreneurship for the legal nurse consultant can be difficult to accomplish, as the resources that would bring value for an effective transition are lacking (Wall, 2013; Wilson et al., 2012). Drennan (2007) and associates agreed that research exploring entrepreneurial activities was devoid. With the absence of available resources that provide valuable and honest guidance, frustration can occur with the new and emerging LNC entrepreneur.
Study Participants
A Southeastern state was initially chosen as the locality to obtain data because of the accessibility of the participants. Additional participants were recruited from the
Northeastern and Midwestern states to reflect diversity within the sample. The study sample included eight participants (n 8). The small sample size allowed for an in-depth examination of the intended context (Yin, 2013). Data saturation was achieved with the sample size when no additional data was obtained relative to the question being explored.
Relevance and insight were produced from the sample size related to the LNC entrepreneurial journey and the study purpose. Data saturation occurred with the depth of understanding. Increasing the sample size would have led to abandoning some of the value of the study (Yin, 2013). An increased sample size would not have allowed for a focused and in-depth exploration. Alvesson and Sandberg (2011) noted that qualitative
102 studies could have small sample sizes that are complete with the saturation of data. The sample size can offer reliable suggestions for the focus of future research.
The education preparation of the study participation varied: 3 LNCs with a
Masters Degree in Nursing; 4 LNCs with a Bachelor of Science Degree in Nursing; 1
LNC with an Associate Degree in Nursing. All participants had a minimum of 5 years experienced as an LNC entrepreneur. Snowball sampling was used to recruit participants that met the inclusion criteria. Participants were provided with an informed consent, with an explanation of the study prior to beginning interviews. Participants were allowed to decline participation in the study.
Statement of the Problem
The increasing need for competent and experienced legal nurse consultants is a result of the increase in medical litigation claims. The successful transition from employee status to entrepreneurship requires the acquisition of skills other than nursing knowledge (Dyck, 2016). Overcoming barriers related to the lack of knowledge and skills to perform successfully as nurse entrepreneurs is required for a successful career transition (Dehghanzadeh, et al., 2016). Yet, useful resources and research is lacking for the emerging entrepreneurial legal nurse consultant (Wall, 2014). This study provided a clear perception and awareness as to difficulties and barriers that are experienced by entrepreneurial LNCs.
Research Method and Design
A qualitative approach with a case study design was used to explore the different perspectives of entrepreneurial legal nurse consultants’ experiences. The purpose of this study was to explore the perceptions of legal nurse consultants regarding the journey to
103 become entrepreneurs. The case study approach permitted contextual information to emerge from in-depth interpretations of entrepreneurial experiences.
Research Question
The research question that guided this qualitative case study was: How do legal nurse consultants describe their journey toward entrepreneurship? The interview questions led the inquiry for exploring the legal nurse consultants’ journey toward entrepreneurship.
Developing Themes and Review of Literature
Themes were revealed through data analysis for this exploratory case study as a result of interviews with eight participants ( 8) using seven open-ended questions. This method allowed for a detailed understanding of the journey toward entrepreneurship for the legal nurse consultant.
Data Analysis
The intent of the interview questions was to capture data that portrayed personal perceptions during the LNC entrepreneurial journey. Throughout the interviews and in response to open-ended questions, participants disclosed experiences associated with their LNC role during their entrepreneurial journey. The responses to the questions seized a distinctive insight into their experiences. The path toward a successful independent LNC practice addressed the research problem as to the deficiency of applicable research. The data was examined and reviewed critically, which allowed for the development of themes from the participants’ stories. The collective themes portray a summative accounting and description of the LNC entrepreneurial journey experience.
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The data revealed that entrepreneurial LNCs are from diverse experiences, education, desires, and pursuits, and with different how-to-resolutions.
The exploratory case study approach permitted attentiveness to the exploration of the perceptions of legal nurse consultants regarding their journey to becoming an entrepreneur. Truthful and candid responses, with a precise accounting of the journey toward entrepreneurship, were assumed. A rapport was established during the interview process to get honest facts and actual course of events associated with the open-ended interview questions.
Data triangulation assisted in strengthening the finding’s credibility. Participant interviews, researcher field notes, Archival documents from the American Association of
Legal Nurse Consultants, an analysis of interview transcripts, and a theme matrix supplied data for triangulation, which was used as a documented accounting of the LNC entrepreneurial role. Using multiple data sources provided a balance for the limitations that could occur from just one data source (Yin, 2014). The multiple data sources also provides for an examination of their benefits (Shenton, 2004). The development of data collection was heightened by triangulation.
Bandura’s self-efficacy theory was the theoretical framework guiding this study.
Bandura (1994) believed that principles of self-reflection were entangled within the beliefs associated with self-efficacy and the capabilities to accomplish tasks. The legal nurse consultants’ experiences provided an alignment with the concepts of confidence, self-determination, proficiency, belief, and motivation, which reflect the understanding of the entrepreneurial legal nurse consultant role (Roggenkamp & White, 1998). Having
105 confidence and faith in personal abilities when meeting stated goals and responsibilities, speaks to the spirit of the self-efficacy concept (Bandura, 1977).
Theme: Determination to be Successful
Bandura’s self-efficacy theory brought meaning to the participants’ insistence that having confidence and being persistent is required for success as an entrepreneurial LNC.
The basic attainment or success of entrepreneurs is the desire to develop a new business venture along with accepting risks along the journey to entrepreneurship. The entrepreneurial progression for the LNC participants started with their wish to be an entrepreneur. Self-efficacy can be found along the continuum to entrepreneurship development (Densberger, 2014). Success is not guaranteed when maintaining a sense of self-efficacy, however, success is more plausible when there is persistence along the journey of entrepreneurship (Densberger, 2014). Confidence feeds the ongoing determination. An individual’s dedication, persistence, and determination is necessary when managing the many challenges and obstacles (Bandura, 2009). The participants overwhelmingly revealed that resilience from those unexpected roadblocks is critical to developing a successful business.
Marketing was found to be a huge consideration for the entrepreneur, which impacts work volume and business success. There is a reminder by Hau (2013) that an essential component of marketing is to be enthusiastic and possess the capability to persuade others that your product will be a valuable asset to them. Persistence is critical to the entrepreneurial journey (Shane, Locke, & Collins, 2003), and those who show tenacity while pursuing those goals, experience more success (Timmons & Spinelli,
2009). P1 noted that roadblocks were an expectation, and those barriers were conquered
106 as they were experienced. The path towards success is shaped with enough opposition and obstacles; ignoring the many factors that do not support positive efforts is critical to reaching the intended goal.
The participants’ responses are consistent with the literature suggesting that receiving support and mentoring is instrumental in being successful as an entrepreneur.
Receiving direction and guidance from other entrepreneur LNCs provide the tools for success. Vatan and Temel (2017) discussed how mentorship is invaluable. The ability to have a peer available to share experiences, provide knowledge or vent during times of discord helps during the transition and neophyte period (Vatan & Temel, 2017).
Stavropoulou and Protppapa (2013) posited that a mentor is helpful to the entrepreneur in need of discovering strengths and releasing self-potential. Data obtained from the participants parallel literature related to the need for a support system as an essential component of entrepreneurial success. P3 was forthright in noting that her success was in direct relation to the help she received from others. Success as an entrepreneur comes with being surrounded by other like-minded, encouraging, and positive individuals, which will be a driving force toward that success (Memon, Rozan, Ismail, Uddin, &
Daud, 2015). Networking is critical to establishing and sustaining entrepreneurial ventures (Memon et al., 2015). The study participants stressed the need for building a support network. Desjardins (2006) believed that mentoring should be a counterpart to nursing and central to professional growth; yet, failing to deliver on that outlook was often the case. P1 concurred, suggesting that she did not receive the support that she expected. The absence of the collegiality of peers is often one of the tradeoffs for the independence of the entrepreneur.
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Acknowledging that mentorship is one of the major elements in a successful path to entrepreneurship, P1, P4, and P5 had the least number of entrepreneurial years and described the struggle that is evident when mentoring is not accessible. P4 specifically recognized that attending networking events helped with her growth as an entrepreneur.
Looking at the history and the inaugural role of the entrepreneurial LNC, opportunities for networking were not plentiful, which prompted the efforts of the National Nurses in
Business Association to support nurses (Bemis, 2011). As the role evolved with increased awareness and recognition of the career option, there has been an increase in networking through LNC conferences and conventions, yet, the cost is often prohibitive.
Flexibility is a driver for the continued efforts as an entrepreneur (Agarwal &
Lenka, 2015). The importance of having control over personal time and schedules was found to be invaluable for the participants. Work flexibility allows for increased work- life balance (Agarwal & Lenka, 2015). With the increased stressors and responsibilities of the current health care system, having control over work schedules can help with managing stress levels (Wall, 2015). P3 noted that she welcomed the flexibility of entrepreneurship, however, she noted that she often ends up working long hours, which requires self-discipline. The participants discussed some of the elements associated with the flexibility of entrepreneurship as a legal nurse consultant, which is also reflected in the current literature. Wall (2015) found that flexibility was one of the advantages to working independently. Flexibility is one of the motivating factors for seeking entrepreneurship (Agarwal & Lenka, 2015; Lee, 2017). As legal nurse consultants, the participants embraced the ability to continue their work in the legal field, while having independence with their work tasks, and the ability to direct and control their workflow.
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Theme: Confidence Related to Performance Capabilities
The initial interview question asked how the participants described the entrepreneurial LNC role. P3 stressed how the entrepreneurial LNC role required more than just nursing knowledge; rather, basic knowledge, living experience, and a good grasp on communication abilities. Reviewing and summarizing medical records for attorney clients and helping clients with understanding the medical issues was a common response of the study participants. The participants described how there are expectations from attorney clients for the LNC to possess a level of nursing knowledge that helps with case analysis (Peterson & McMullen, 2007). Milazzo (2007), Neil (2013), and Zorn and
Schwarz (2016) noted that attorneys have come to realize the advantage of using the LNC to increase efficiency when doing the case preparation, which was reflected in the participants’ interpretation of their role.
Participants described how self-confidence impacted their ability to be successful as an entrepreneur. The participants’ responses largely echoed the literature, which suggests that moving forward with a successful entrepreneurial business and quality performance requires a measure of self-confidence. The participants’ view aligned with
Andrica (1998), Dyck (2016), and Revell-Love and Revell-Love (2016) in that confidence was critical to success as an entrepreneur, with no room for self-doubt. The data support previous research indicating that a critical tendency toward entrepreneurship is self-confidence in entrepreneurial capabilities, which is akin to entrepreneurial self- efficacy (Kirkwood, 2009). The participants’ believed that lacking self-confidence would undoubtedly lead to a more difficult path toward entrepreneurship.
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There was an alignment between the participants’ description of the LNC role and entrepreneurship and the literature reviewed. The LNC portrait resembles one who applies nursing knowledge, reviews medical records, and collaborates with attorneys and other entities, such as insurance companies, and governmental agencies, while delivering clarifications of medical terminology and evaluations of standards of care (Neil, 2013;
Shumaker, 2013; What is an LNC, 2019). The LNC’s role to educate clients, no matter the entity, clearly resonated through the participant’s responses. The study participants’ response gave credence to Milazzo (2007), Neil (2013), and Zorn (2015) contention that the independent LNC is a critical participant to the litigation team. Neil (2013) and
Castellana (2014) agreed that educating the client is the primary role of the LNC. The participants’ insight into the LNC role undoubtedly paralleled the literature as to the intent and role of the LNC. As the participants suggested, attorneys depend on LNCs to inform and identify relevant information while determining the merits of a case and preparing the case disposition (Castellana, 2014).
Having the capability to capitalize on acquired nursing skills and experiences is validated in the historical nature of nursing. Those capabilities help in managing the demands of a role transition to entrepreneurship (Smeaton, 2003). Standing firm with your convictions, opinions, and abilities was revealed in the study results, which was in line with the beliefs of Oksana and associates (2015) and Wilson, Kickul, and Marlino
(2007), in that self-confidence is based more on perceptions of expertise and capabilities.
P1’s description of the impact of self-confidence on entrepreneurship, noted, “well, I got over 40 years of nursing, so, I figured that I could utilize that” paralleled Adomako,
Daso, Uddin, and Ofori-Damoah (2016) and Koellinger, Minniti, and Schade’s (2006)
110 belief that entrepreneurs exhibit greater degrees of overconfidence than others in the general population. P2 was adamant in her representation of how LNCs should present themselves to attorneys. The ability to lose focus while on the entrepreneurial path is easy. However, being decisive with a strong level of self-confidence, not showing intimidation was an expectation for the successful entrepreneur (P2). The length of entrepreneurship was a telling factor in the comfort level and confidence exhibited by the participants.
Entrepreneurial Journey
Exploring the personal experiences of entrepreneurial LNCs has provided a chance to develop a deeper awareness and insight into the responsibilities and challenges of entrepreneurship. Understanding the difficulties, obstacles, and the needed strategies for success is necessary for the LNC who has determination while laying the groundwork for the entrepreneurial journey. Having a confident spirit not only when producing their work product, but also with client interactions resonated with the participants.
It did not matter if the participants’ background included an extensive skillset, was new to entrepreneurship or had a significant educational background; the determination and a sense of confidence were undeniable components of the journey toward entrepreneurship. Only one of the participants had formal legal nurse consultant training. However, having an extensive nursing experience provided a degree of confidence that might not be so evident in other career disciplines seeking entrepreneurship. There was no question that success would come because of the depth of their experience. Brown (2019) discussed how nurses are poised to be exceptional business owners as a result of the development of critical thinking, coordination, and
111 prioritization skills. P1 boasted of her 40 years of nursing experience. P3 was proud of the many specialty areas in which she worked, and knew that using that experience would make her more marketable in the legal industry. P6 emphasized her experience as a critical care nurse and how there was not one attorney who could measure up to her level of knowledge.
The research sample did not reveal one specific path that propels registered nurses into the LNC entrepreneurial role. The one commonality among the participants was having the desire for entrepreneurship. P3 believed there was a natural progression into the entrepreneurial role while pursuing a similar career. P1 revealed there was a longing for another career choice after retirement from an extended clinical practice, while P2 wanted a supplemental career option. P4 just wanted a career change and thought legal nurse consulting would be a good choice. P6 also knew she needed another career path to meet the needs of the family. P8 evolved after being approached by an attorney for doing a great job as a witness in a hospital court case.
The participants discussed the benefits of peer support and how success for the
LNC is often dependent on a network of other entrepreneurs. While working from home provides independence and work flexibility, the research sample described the challenges of working in silo. The absence of readily available peers or mentors to maintain a network of support should be a realization for the LNC entrepreneur. P5 admitted to not having access to mentors when starting on her journey. While mentoring was found to be an invaluable resource, data collected from the more seasoned participants did not stress the advantage of having peer support at the same level as those with just 5 years of experience. Offering mentoring to others is provided by P8 as a seasoned LNC. P3 and
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P4 discussed the value of having collaborative relationships with other LNC entrepreneurs, while P1 was adamant that mentoring was very important for being successful. Mentors are often identified in convention gatherings, however, as noted by
P3, the fees for conventions are expensive and often cost-prohibitive. The participants’ perspective on the value of peer collaboration aligns with Elango’s and partners’ contention that collaborative attempts could drive efforts in overcoming barriers to successful entrepreneurship.
The financial component of entrepreneurship lends itself to possible risks of business solvency. P6 stressed the importance of acquiring business savvy, which is not taught in nursing school. Having the determination to be successful came into play as the
LNC entrepreneurs weighed the benefits of creating a business against the risks of failure.
Being creative, identifying business prospects, and maintaining clients is important to sustained entrepreneurship. P3, P4, and P5 discussed how marketing is important to maintaining financial stability. Being determined and willing to accept risks along the journey was an important achievement for the participant entrepreneurs, which was also representative of the views of Titus (2011) for business success. Realizing that determination is associated with successful outcomes, P4 believes that persistence is necessary during the entrepreneurial journey, while remembering that being persistent was a part of her rearing mantra. The participants knew there needed to be a determination as to the needed resources, whether those resources were financial or equipment-based, such as a computer and computer software. P1 and P4 remembered the initial struggle as to the appropriate purchases associated with starting a business. P1 remembered purchasing equipment that was found to be unnecessary. P2 recalled a
113 lesson-learned after submitting an invoice for the work she completed. P7 recollected spending several thousand dollars on marketing materials that went unused. In spite of challenges and barriers associated with entrepreneurship, the participants have maintained their business for a considerable career span. The entrepreneurial journey of the study entrepreneurs covered the stages of development, which started with recognizing an opportunity, determining a service need, and then building a successful business.
The development of the participants’ journey mirrors the historical overview of the concept of entrepreneurship. An entrepreneurial venture begins with a business concept or thought and includes accepting risks. Historically, success for entrepreneurs is relevant to the skillset, the understanding, experience, and training. Those same elements were evident in the data. Nurses have worked independently since the 1920s (Faugier,
2005). Looking at the impact that entrepreneurship has had in nursing and healthcare, P3 stressed the importance of having an LNC class nestled within the basic nursing program curricula.
Limitations
The study included several limitations including the availability of LNCs. During the course of data collection, the selected AALNC chapter ceased operations. It could not be determined if the lack of response from direct solicitations was due to the chapter’s operational status or not. Therefore, a snowball sampling technique was added to the recruitment protocol, as well as widening the sample to include the Northeastern and Midwestern states. The small sample size lessened the capability to generalize
114 findings and was not anticipated to characterize the whole population of LNC entrepreneurs.
Limitations of this exploratory case study consisted of the lack of experience of the researcher, as well as potential bias (Noble & Smith, 2015). Due to the researcher being an instrument in the data collection process, bias cannot be entirely removed from the qualitative approach. Bias was minimalized in this case study through the process of preserving honesty and candidness of the data (Noble & Smith, 2015). Bracketing was used prior to data collection as an approach to minimize the influence of prejudices that could cause bias during the research process (Tufford & Newman, 2012). The researcher was willing to pay attention and be receptive to the different viewpoints and perceptions during data collection. The researcher put aside any prior knowledge related to the entrepreneurial LNC to acknowledge the participants’ personal views and preconceptions.
Additionally, there was an absence of the male participant, which left the study missing the male viewpoint. The ability to contrast and compare the differences in gender as studied by Kirkwood (2009) might have provided a broader perspective as to the entrepreneurial experience.
Study Implications
Previous research is lacking that reveal candid representations and interpretations of the legal nurse consultant’s journey toward entrepreneurship. An exploration of the legal nurse consultant’s path toward entrepreneurship provided additional insight into the creation and maintenance of a successful business. Having determination, self- confidence, and motivation is vital to success for the entrepreneurial LNC. Data revealed
115 that there are specific challenges associated with becoming a successful entrepreneurial legal nurse consultant. When considering an entrepreneurial LNC venture, a focus on the accessibility of mentorship and networking should be paramount, to increase the likelihood of success. Through mentoring, the development of the necessary tools of the trade is possible; such as embracing the worth of nursing knowledge, marketing for new clientele, producing quality work products, and the most efficient way to ensure payment of services.
Implications for Nursing Practice
While the participants no longer practice in the clinical setting, the capability to transfer nursing knowledge and expertise is critical to establishing an entrepreneurial business. While P1, P3, and P4 inferred that minimal resources and guidance is given to ensure the job is done correctly and efficiently, P6 recommends accessing resources through the AALNC as the organization that sets the LNC entrepreneurial standard.
Reliance on foundational nursing knowledge is essential for the LNC entrepreneur. P2 described how “looking up standards reminds you of what you’re supposed to be doing”, noting that standards change over time. Continued awareness of known nurse practice standards is paramount to the LNC entrepreneurial practice.
Being innovative and creating a business for the professional registered nurse is possible. Nurses should know there is a need to safeguard the longevity and fiscal future of the profession. With the current and impending changes to the health care system, nurses are charged with diversifying their practice to integrate business astuteness. The results of this study gave credence to Wall (2013), which demonstrated the value of career advancement and a unique career opportunity that will take advantage of the
116 efficient use of nurses. The history of the nursing profession was entangled with social entrepreneurship, which had a great impact on the health of the community (Faugier,
2005). Entrepreneurship for the LNC is in a unique position to have a positive impact on the profession of nursing and the legal community.
Implications for Nursing Leadership
Role development for the LNC entrepreneur was found to be a needed element in the entrepreneurial process. Developing a strong sense of confidence, especially when providing medical opinions is very important to the leadership component and developing client relationships. An important element of the LNC entrepreneurial role is having the ability to know your worth and standing firm in your conviction and opinions
(P2, P6). Competencies and expertise mark the necessary abilities important for the entrepreneurial nurse to achieve effective leadership (Danna & Porche, 2009).
Maintaining a strong sense of confidence of the role’s expectations, along with innovation and initiation will help to develop leadership skills. Nurse entrepreneurs have been expanding the capabilities of the nursing profession, which require insight and strong leadership capabilities (Faugier, 2005). Being a good decision-maker in this independent role is paramount for the successful LNC. The entrepreneurial LNC must have a clear vision, be resilient, and understand that decisions will impact the future of their business.
Implications for Nursing Education
Further consideration is needed related to the education of nurses that focus on innovative and entrepreneurial opportunities. Wall (2013) suggested nurse education programs do not prepare entrepreneurs for the role. Adequate preparation for the LNC
117 entrepreneurial role will provide the resources to be successful when seeking an alternative career path. P3 was adamant in her belief that a legal nurse consultant course embedded within the undergraduate curricula would be beneficial in providing the tools and means to manage different entrepreneurial scenarios. The LNC must be in a position to avoid mistakes while taking on more responsibility (P3). P2 agreed that education was vital to knowing what to do to help build the confidence level. P6 believes it is important to be armed with the information related to what it means to be an LNC; taking a course should be the initial step.
Recommendations
As a result of an analysis of the perceptions of eight LNCs who participated in this study, recommendations were developed, which are associated with two major themes that emerged. Table 5 offers a snapshot of the recommendations shaped by the two themes.
Table 5
Recommendations
Realm Recommendations Nursing Practice Identify different perspectives for nurse practice Disseminate entrepreneurial outcomes to nursing groups Enhance professional makeup through entrepreneurship Nursing Leadership Emerge as change agent and decision maker Intentional leadership Effective abilities bsuccess Nursing Education Need for LNC course in nurse education curricula Provide resources to ensure success Nursing Research Qualitative study focused on the worth of LNC Replicate research with larger sample in additional regions to validate themes Research to focus on failed entrepreneur efforts
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Nursing Practice
This study focused on LNCs who continue to practice in the entrepreneurial role.
There is a need to identify and expose the different perspectives of the legal nurse consultant performing in independent practice. Research related to the successes and failures of entrepreneurial LNCs should be disseminated through publication and the many venues where nurses gather, such as state and national nurses association conventions and other gatherings. LNC entrepreneurship can be promoted by using approaches, such as inspiration that impact views and impressions of self-efficacy related to work independence. Participants stressed the importance of networking and the impact on a successful practice. Informing nurses as to the qualities of entrepreneurship and business expertise, which is essential for the role, might help to increase or bolster the perceptions of self-efficacy, and ultimately nurse practice. Nurses that possess the spirit of entrepreneurship such as visionaries and innovators can enhance the make-up of their professional nurse practice.
Nursing Leadership
Registered nurses transition into many roles during their professional season, which undoubtedly includes the enhancement of leadership capabilities. The LNC entrepreneurial role emerges as a change agent, which is seen as a visionary, a decision- maker, and the key to conflict resolution. Nurses should possess the fortitude and resourcefulness to lead for change with a focus and motivation for entrepreneurship.
Registered nurses have a greater potential and capability for the leadership role outside the familiar walls of hospitals and other organizations that require the employee status.
However, having a seat at the board table is not enough. Developing the leadership
119 skillset that is enhanced with the entrepreneurial role, prepares registered nurses with also having a voice at that table to impact change within the healthcare system. The dissemination of research that has explored those capabilities is needed.
Entrepreneurship is an optimal role suitable for supporting the readiness of nurses for leadership in the changing health care climate. Leadership and strength while in the entrepreneurial role promote innovations within the health care system. Entrepreneurship is an opportunity for critical thinking skills and different practice areas to develop into a business opportunity. Effective entrepreneurial leadership ability is the fuel that propels one to success (Faugier, 2005; Wilson et al., 2012). Research is needed that supports and validates the LNC entrepreneurial role with its impact on the medical-legal continuum, which requires steadfast leadership capabilities.
Nursing Education
Participation in a formal training program is not a requirement to become a legal nurse consultant. Research that determines the impact of formal education for the aspiring LNC entrepreneur could add an additional layer and platform to explore the entrepreneurial journey. The AALNC insists that nurse education programs should integrate legal nurse consulting as a specialty area within the curricula (AALNC, 2017.).
Educational opportunities that include elements of leadership are critical to the nurse roles, which resemble entrepreneurship as an alternative career choice. Having LNCs surprised about the true workings of entrepreneurship when aspirations arise, seems unwarranted when information can be introduced in the formal nurse training setting.
Aside from the basic nursing education and clinical skills, a qualitative study could explore the additional factors that ensure entrepreneurial success.
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Recommendation for Further Research
Most of the current research discusses the benefits of entrepreneurship, including being your own boss and the income potential that exists with self-employment.
However, little research explores specific challenges associated with nurse entrepreneurship. The current research findings helped in closing the gap in the literature related to increasing knowledge related to the experience of the entrepreneurial legal nurse consultant. Further research might produce additional ideas related to the path of entrepreneurship for the legal nurse consultant.
Research validates current knowledge and generates additional information while guiding practice. Research related to failed LNC entrepreneurial attempts might provide additional perspectives as to some of the challenges that are experienced during the journey toward entrepreneurship. As well, a qualitative study directed at the worth of the
LNC entrepreneur is needed to give credence to the specialized practice. The study could generate findings that would support nurses who seek alternative and non-traditional career options while identifying the value of the professional nurse as an LNC.
Additional recommendations for future research would be to duplicate the study in additional regions with a larger sample to validate themes and findings. The study participants were female entrepreneurial LNCs. With the absence of the male perspective in this study, further research exploring the differences in entrepreneurial experiences between the male and female LNC might disclose additional facts related to the success or failure of the path to entrepreneurship.
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Researcher Reflection
This researcher was a little surprised that the participants did not discuss passion for the LNC role in relation to entrepreneurial success in more depth. As there is so much independence as an entrepreneur, feeling a strong desire to be successful is often related to the thirst and desire for professional growth to continue pushing forward.
Powell (2017) found that passion is essential to the work you do. However, this researcher has been inspired by the level of commitment to the legal nurse consultant role shown by the participants. Exploring the experiences of the entrepreneurial LNC provided an opportunity to gain a greater understanding and insight into those that possess a desire to continue in the LNC role. This study provided a means for transparency while validating the entrepreneur’s path with a stronger understanding of the value of entrepreneurship. Nurse entrepreneurship is not the obvious image of nursing. Nurse entrepreneurs have accepted the torch to be leaders toward changing the look of the nursing landscape.
Conclusion
The paucity of literature that depicts the legal nurse consultant as an entrepreneur was the motivation for conceptualizing this study. The purpose of this qualitative exploratory case study was to explore the perceptions of legal nurse consultants regarding the journey to become entrepreneurs. The research question that guided this study, was how do legal nurse consultants describe their journey toward entrepreneurship?
The pattern-matching and coding technique guided the data analysis process (Yin,
2014). Themes were identified through the process of reviewing transcripts and audio recordings, followed by data triangulation. Different data sources were linked through
122 triangulation in determining conclusions and to enhance data analysis. Triangulation of data included participant interviews, analysis of transcriptions, theme matrix, researcher field notes, and secondary data from the AALNC, which strengthened the finding’s credibility with additional perspectives. Data triangulation assisted with lessening prejudices, bias, and predeterminations while providing added significance to the research outcomes (Shenton, 2004). The process of data collection was improved with triangulation during the analysis.
Two main themes were revealed through data analysis. The themes that emerged are confidence related to performance capabilities and determination to be successful.
The identified themes support the role and work that is necessary for the entrepreneurial
LNC.
The journey toward entrepreneurship as an LNC was varied for the participants.
However, the ingredients for a successful entrepreneurial business were similar. The participants were clear that the journey was not without challenges. As a valuable addition to the legal team, their legal nurse consultant’s work was built on the nursing expertise of general nursing practice. There is a clear indication of the need for persistence, which was resonated with all the participants. While the LNC is an integral bridge between medicine and law, access to adequate resources for success is scarce. The participants expressed that support from peers was felt to be a huge indicator of success for them. Networking was believed to be an integral part of the entrepreneurial experience. The participants want to know that support is available when the decision is made to pursue entrepreneurship. However, even though mentorship is a determining factor for success it is not always readily available to the entrepreneur. It was believed
123 that an intentional propensity for confidence and determination is critical to the entrepreneurial journey. Confidence is a necessary component of the skillset for the entrepreneurial legal nurse consultant.
The findings from this study added to the limited existing research related to entrepreneurship as a legal nurse consultant. The participants validated the information found in the literature describing the role of the legal nurse consultant. As registered nurses, legal nurse consultants can benefit from their acquired skills, information, and experiences to manage the role change to entrepreneurship. The findings were consistent with previous knowledge that entrepreneurship for the LNC provided another professional choice for the registered nurse. The transition to entrepreneurship seemed like a natural path for the participants, especially with the desire to establish work flexibility, increased worth, and control of their career path. The entrepreneur LNC will find that the responsibility for business success is a personal one, along with the rewards that will be realized, which helps with cultivating confidence.
There continues to be a knowledge gap, and lack of adequate support related to the business side of entrepreneurship for the LNC, such as marketing and invoicing practice requirements and competency. Entrepreneurial legal nurse consultants do recognize and value the need for the LNC role and must continue to be motivated and have the capability to overcome possible hurdles.
Summary
The purpose of this qualitative exploratory case study was to explore the perception of legal nurse consultants regarding the journey to become entrepreneurs. The major themes identified included: confidence related to performance capabilities and
124 determination to be successful. Chapter 5 discussed the study findings, theme clarification, and recommendations as a result of the findings, implications, and suggestions. An evaluation of the themes are included, influences for new knowledge, limitations, and conclusion. LNC entrepreneurs are innovators that possess a drive to succeed while undertaking and assuming challenges. Findings from this study add to the body of knowledge and support the LNC entrepreneurial role based on the perspectives of the current LNC role.
125
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Appendix A
Interview Guide
The subject of my dissertation is, exploring perspectives of legal nurse consultants as entrepreneurs. Your participation in this study is voluntary.
Your participation will entail one-on-one interviews, which will last approximately one hour. There will be several questions that will be related to your experience as an entrepreneurial legal nurse consultant. You will be required to provide written consent to participate in this study. With your permission, your interview will be audiotaped to ensure accuracy. However, your identity will be kept confidential. You may withdraw from the study at any point, for any reason. If you decide to withdraw, any information obtained to that point will be destroyed and will not become a part of the study. The results of the research study might be published, however, your identity will remain confidential and your name will not be known to any outside party. There are no predictable risks to you for your participation.
The following questions will be used when interviewing the participants. Clarifying questions may also be used.
1. How would you describe your role as an entrepreneurial legal nurse consultant?
2. What barriers and enablers did you experience on your journey to becoming an entrepreneur?
3. What were your expectations as you developed your role as a legal nurse consultant entrepreneur?
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4. How does belief and self-confidence play in the ability to be successful as an entrepreneur?
5. What are some encouraging experiences related to your decision to become an entrepreneur?
6. What advice would you give to another legal nurse consultant interested in becoming an entrepreneur?
7. Thinking about your experience becoming an entrepreneur, are there any other things you think may benefit other entrepreneurs or those aspiring to become entrepreneurs?
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Appendix B
Solicitation Letter
Dear ______:
My name is Evelyn H. Bell and I am a student at the University of Phoenix
School of Advanced Studies pursing a Doctor of Philosophy in nursing degree. I am conducting a research study entitled Exploring Perspectives of Legal Nurse Consultants as Entrepreneurs: A Case Study. The purpose of this case study is to explore the perceptions of legal nurse consultants regarding the journey to become entrepreneurs.
The research design is qualitative exploratory case study that will entail the use of various sources.
Your participation will entail an audiotaped interview to ensure accuracy.
However, your identity will be kept confidential. The interview will be held via
SKYPE™ at a mutually agreed upon time. During the interview, you will respond to questions related to your personal journey toward entrepreneurship, while providing a description of those experiences with an explanation of the spirit and essence of being a nurse entrepreneur. The interview will last approximately 60 minutes. Your participation in this research study is voluntary.
You may withdraw from the study at any point, for any reason. If you decide to withdraw, any information obtained to that point will be destroyed and will not become a part of the study. The results of the research study might be published, however, your identity will remain confidential and your name will not be known to any outside party.
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There are no predictable risks to you for your participation. This study would bring value to the nursing profession while identifying key factors essential for success as an entrepreneur. Email and contact information provided in the event of any questions or concerns related to the research study.
By signing this form you acknowledge understanding of the nature of the study and potential risks. You acknowledge that you are 18 years old or older and that your identity will be kept confidential. You give permission to serve voluntarily as a study participant.
Signature of the interviewee______Date______
Signature of researcher______Date______
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Appendix C
Informed Consent: Participant 18 years of age and older
Dear _____,
My name is Evelyn Houston Bell and I am a student at the University of Phoenix working on a PhD in nursing degree. I am doing a research study entitled Exploring
Perspectives of Legal Nurse Consultants as Entrepreneurs: A Case Study. The purpose of the study is to explore the perceptions of legal nurse consultants regarding the journey to become entrepreneurs.
Your participation will involve a one-on-one interview, which will last approximately one hour. There will be several questions that will be related to your experience as an entrepreneurial legal nurse consultant. You will be required to provide written consent to participate in this study. With your permission, your interview will be audiotaped to ensure accuracy. However, your identity will be kept confidential. You can decide to be a part of this study or not. Once you start, you can withdraw from the study at any time without any penalty or loss of benefits. The results of the research study may be published but your identity will remain confidential and your name will not be made to any outside party. In this research there are no foreseeable risks to you. The risks are none.
For questions about your rights as a study participant, or any concerns or complaints, please contact the University of Phoenix Institutional Review Board via email at
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As a participant in the this study, you should understand the following:
1. You may decide not to be part of this study or you may want to withdraw from
the study at any time. If you want to withdraw, you can do so without any
problems. You can contact me by phone or email.
2. Your identity will remain private and kept anonymous. Information obtained from
your interview will remain confidential. A coding process will be established and
codes will be assigned to each participant, which will only be available to the
researcher.
3. Evelyn Bell, the researcher, has fully explained the nature of the research study
and has answered all of your questions and concerns.
4. Your interview will take place via SKYPE™; however, there will be no
SKYPE™video recording.
5. Interviews will be audiotaped with the use of a handheld digital voice recorder.
You must give permission for the researcher, Evelyn Bell, to audiotape the
interviews. You understand that the information from the recorded interviews will
be transcribed. The data will be coded to assure that your identity is protected and
maintained.
6. Data obtained from interviews will be kept secure. Data will be kept in a locked
file cabinet in the researcher’s home office. The data will be kept for three years,
and then destroyed. The researcher will reconfigure the audio recordings and
electronic records.
7. The results of this study may be published, however, your identity will remain
confidential and your name will not be known to any outside party.
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“By signing this form, you agree that you understand the nature of the study, the possible risks to you as a participant, and how your identity will be kept confidential and anonymous. When you sign this form, this means that you are 18 years old or older and that you give your permission to volunteer as a participant in the study that is described here.”
( ) I accept the above terms. ( ) I do not accept the above terms. (CHECK ONE)
Signature of the research participant ______Date ______
Signature of the researcher ______Date ______
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Appendix D
Theme Development
______Theme Quote ______
Confidence Related to Performance Feel confident in your work (P1) Capabilities I see my role as being able to add value by reviewing the charts, giving clinical information and being able to educate and provide information back to the client, so that they understand the medical and they also understand the standard of care related to that injury (P1) I review medical records for attorney, and provide health and safety consultations and education related to standards (P2) You have to be able to present yourself well to your clients. Particularly in the legal nurse consultant world, attorneys are intelligent, sharp, judges of people. They want somebody who can take a position and stick with it and not be dissuaded. I liken it a lot to when nurses contact physicians about a clinical situation; they have to be able to present their opinion, describe what’s going on, stand firm and not be intimidated and get what they need for their client, in this case, their patient. If you lack self-confidence it’s going to be a much harder road, as an entrepreneur and that would dissuade many people from even attempting to start a business. You have to have confidence in yourself to be able to speak your opinion; be able to defend your opinion. Know your value. Don’t allow anyone to bully you (P2) Self-confidence plays a huge role. I guess if you get into an area that’s your niche, you’re self-confident (P3) They want every bit of knowledge you can give them to make a case. Those attorneys are banking on your knowledge. They want you to be able to say what are the results of injury/trauma that has occurred, or, what’s going to happen in 10 years from now. A legal nurse course gets you to the point of learning how to assess the medical information; to be able to do it, and walk into an
151 attorney office and take any kind of case. It appears that the ones that make that transition easier, are those that have both worked in the inside clinical setting and an outpatient setting and have actually like case management background. Where they’ve been involved on the legal side worked with both the defense and plaintiff, almost mediating both sides, gives a better perspective (P3) I think for a lot of people it may not be quite a unique sort of thing. It was the way I was raised; encouraging me that I can be anything that I want to be and do anything that I want to do. I continue to build on that (P4) If you are not confident with your work, the first time you have any communication with an attorney, you are so intimidated; you have to be confident about your experience as a nurse. Confidence plays a huge role in getting your business up as a brand new LNC. If you don’t you might as well stick with subcontracting. If you can’t sell yourself, if you can’t market yourself, you don’t have confidence in your work product and your experience as a nurse, you are going to have to subcontract and take an extremely lower rate. I think I had pretty good self- confidence in my experience and my abilities prior to getting into it. Meek-type personality doesn’t gel right with entrepreneurship. You have to exude, you know “I can help you”…”this is what I can do” (P5) I knew that I had the knowledge base and skillset that would allow me to practice in a way to still utilize my education and expertise. The major thing that you’re doing when you do this kind of work, you have to sell yourself. As a critical care nurse I worked independently; there were standing orders and you took the initiative to jump up and do whatever it was you needed to do. There was independence and the confidence that developed from doing that. So, when I came outside the hospital into legal nurse consulting, there wasn’t a single attorney who could tell me they knew more than I did, because I know they don’t. That confidence leads you to a place where you become a partner and an ally (P6) You need to be almost over confident. A lot of LNC work is deadlines and knowing what you’re doing.
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If you don’t know what you do, and you can’t achieve that deadline, they’ll never hire you again (P7) Need confidence as a quality of an entrepreneur as a LNC. Coming from nursing, I felt that I could play a role in that aspect as a legal nurse consultant. You have to go to court, you have to be able to speak to the jury (P8) Independent practice may appeal to a nurse who is self-motivated, works well independently, and is self-confident and assertive…to develop and maintain a successful business (AALNC) For nearly 30 years, legal nurse consultants have acted as collaborators, strategists, and educators by offering support in medical legal litigation. LNCs bring their…clinical expertise to healthcare and medically related issues in the litigation process. The practice of legal nurse consulting is performed in collaboration with attorneys. (AALNC) With 40 years of nursing experience P1is confident in her ability to perform LNC entrepreneurial tasks (P1 Field Notes) Must have thick skin. Know your value. You get more confidence with experience (P2 Field Notes) Self-confidence comes with experience and there is an increase in confidence when accepting cases in your specialty area (P3 Field Notes) Self-confidence comes from encouragement (P4 Field Notes) No way to be successful without confidence; have to know how to market yourself (P5 Field Notes) Confident that skillset would help with success as entrepreneur. Worked hard after taking LNC course (P6 Field Notes) Have to be confident with skillset (P7 Field Notes) Need confidence to be entrepreneur (P8 Field Notes) ______
Determination to be Successful But I usually do very well when I take on a new task, or a new job, or a new part of my life. I just go for it, and if there are drawbacks or missteps, that’s just expected. So, they really didn’t take me by surprise. I deal with it as I go. If a person really wants to do it, you got to stick with it. It depends on the determination; you know. It is hard. It’s very
153 hard as far as, you know, keeping clients. If you have people to do the marketing and billing for you that’s even better; it makes it a whole lot easier. But, to me, that’s the hardest part, so, just stick with it and find help when you can get it. (P1) I just assumed that I could work from home on my own time. The ability to have more control or flexibility was a big factor (P1) I think when I started there wasn’t a lot of explanation of what I was doing. I was able to contact another LNC; I was able to contact her when I had questions. (P1) I knew that I had the capability of making money; I looked for what are the different ways I could make money. Spending sufficient time to build the groundwork is important. (P2) Doing in-house stuff, I feel like you’re probably a little more restricted than doing it on your own. (P2) So it’s a very difficult line. When you say I’m going to do this, unless you are continuing to work, which it will be very hard to work full time job and do this, and give it all you got. I mean, it will be very difficult. There isn’t the support when you go out on your own. And you have to be very willing to do it all by yourself. You have to be very self disciplined. And sometimes, that’s not good for some people. You have to be very motivated. (P3) I wanted something that I could do in which I called the shots; and I needed balance, something that I wanted and could do easily at home, or now electronically take with me wherever I go. I wanted some flexibility in my schedule. But, you know flexibility also means when you’re working for yourself, you work all night long sometimes. And, so, you know you have to be very self-disciplined. (P3) There isn’t the support it should be. I think it’s hard because, if you don’t have a lot of support around you, to be able to call another nurse and say, hey, this attorney said this; does this sound right? It’s hard because some of these people won’t provide or share their information for fear that they’re going to go out and be better than they are. I am willing to help someone in any way that I can, because I would not be here today, where I am without the help of someone in my past. And we should all
154 remember that. (P3) I think the passion to succeed and have a successful business drives you to continue to pursue. I can be anything that I want to be and do anything I want to do; not giving up and continue to strive. (P4) Networking is a great way; attending various bar association meetings, attending other legal nurse consultant events where you meet other legal nurse consultants and share ideas and discuss some of the challenges that they’re having and kind of brain storm. (P4) It’s a drive that you have to have; personally driven, a goal for me. You can have people say that you’re doing a great job, or whatever. It has to come from within to push you. I didn’t have anybody say you suck at this, so, you need to stop. I mean nobody ever said that. I got feedback, some was positive, some was negative, but you just keep going (P5) I took the Vicki Milazzo course; I feel like I learned everything I needed to. I spent a week away from my home. I did the intensive study, and I came home and did everything she suggested, and it worked for me. It’s important to arm yourself with what it is you need to do. Learn as much as you can about what it is you’re trying to do. I went to the Small Business Association (P6) The marketing side of it, getting myself out there and getting my name in front of people and that’s why I did medical textbook reviews to try to get my name out there (P7) My fear was speaking with a lawyer, but I quickly got through that. (P8) The independent practice of legal nurse consulting can be interesting, flexible and rewarding, but a LNC needs to decide whether (s)he has the ability, personality, and resilience to meet the demands of building and sustaining an independent practice. Before starting an independent practice, there should be the ability to work independently, yet consult with attorneys and LNCs (AALNC) Strong work ethic and willingness to accept responsibility for seeing projects through to their conclusion, ability to work independently…and unquestionable ethics characterize the independent LNC (AALNC)
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There was an opportunity to stay in nursing, while having the opportunity to continue to learn; welcomed the challenge, knowing it was what she needed (P1 Field Notes) Building the groundwork is important to be successful (P2 Field Notes) Collaboration is important, but not always easy to get support from others (P3 Field Notes) There is an inner drive. Success requires hard work. Understanding entrepreneurial risks and challenges are necessary when moving toward success (P4 Field Notes) Need willpower to continue (P5 Field Notes) Worked hard after taking LNC course (P6 Field Notes) Tried different strategies to get started (P7 Field Notes) Had fear quickly learned best way to approach attorneys (P8 Field Notes)
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Appendix E
Exploring Perspectives of Legal Nurse Consultants as Entrepreneurs: A Case Study
CONFIDENTIALITY STATEMENT
As a researcher working on the above research study at the University of Phoenix, I understand that I must maintain the confidentiality of all information concerning all research participants as required by law. Only the University of Phoenix Institutional
Review Board may have access to this information. Confidential information of participants includes but is not limited to: names, characteristics, or other identifying information, questionnaire scores, ratings, incidental comments, other information accrued either directly or indirectly through contact with any participant, and/or any other information that by its nature would be considered confidential. In order to maintain the confidentiality of the information, I hereby agree to refrain from discussing or disclosing any confidential information regarding research participants, to any individual who is not part of the above research study or in need of the information for the expressed purposes on the research program. This includes having a conversation regarding the research project or its participants in a place where such a discussion might be overheard; or discussing any confidential information in a way that would allow an unauthorized person to associate (either correctly or incorrectly) an identity with such information. I further agree to store research records whether paper, electronic or otherwise in a secure locked location under my direct control or with appropriate safe guards. I hereby further agree that if I have to use the services of a third party to assist in the research study, who will potentially have access to any confidential information of participants that I will
157 enter into an agreement with said third party prior to using any of the services, which shall provide at a minimum the confidential obligations set forth herein. I agree that I will immediately report any known or suspected breach of this confidentiality statement regarding the above research project to the University of Phoenix, Institutional Review
Board.
/______Evelyn Bell______10/17/2016
Signature of Researcher Printed Name Date
______Dr. Anne Brett 10/17/2016
Signature of Witness Printed Name Date
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